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RD581F941896    The  modem  treatment 


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THE  MODEEN  TREATMENT 


STONE  IN  THE  BLADDER  BY  LITHOLAPAXY. 


THE 

MODEEN   TREATMENT 

OF 

STONE  IN  THE  BLADDER 

BY 

LITHOLAPAXY. 


A   DESCRIPTION   OF   THE   OPERATION  AND  INSTRUMENTS, 

WITH  CASES  ILLUSTRATIVE  OF  THE  DIFFICULTIES 

AND    COMPLICATIONS  MET    WITH. 


P.    J     FREYER,    M.A.,    M.D.,    M.Ch., 

Surgeon  Lieut. -Colonel,  Bengal  Army  {retired). 


SECOND    EDITION. 


NEW    YORK: 
WILLIAM     WOOD     AND     CO. 

[All  rights  reserved.} 


3  PEEFACE. 

In  this  little  work  I  aim  at  placing  before  my  professional 
brethren  a  guide  to  the  modern  treatment  of  stone  by 
litholapaxy  of  a  thoroughly  practical  character.  In  addition 
to  a  detailed  description  of  Bigelow's  operation  and  the 
instruments  employed  therein,  I  have  devoted  particular 
attention  to  the  difficulties  and  complications  met  with,  and 
illustrated  these,  and  what  I  consider  the  best  means  of 
dealing  with  them,  by  detailed  eases  from  my  own  practice, 
now  extending  to  more  than  six  hundred  cases  of  this 
operation. 

The  present  edition  has  been  thoroughly  revised  ;  a  new 
chapter  is  added,  giving  details  of  those  precautions  necessary 
in  the  operation  as  applied  to  male  children,  and  to  females 
of  all  ages;  and  some  difficulties  untouched  in  the  former 
edition — notably,  the  removal  of  encysted  calculus  by  the 
modern  operation — are  described  and  illustrated. 

A  new  method  of  diagnosis  for  small  calculi,  first  brought 
to  the  notice  of  the  profession  by  me  in  1884,"  is  illustrated 
and  elaborated. 


vi  PREFACE 

I  have  to  thank  the  medical  press  generally  and  many 
leadmg  surgeons  for  their  very  favourable  reception  of  the 
former  edition  of  this  work ;  and  it  is  particularly  gratifying 
to  me  to  learn  from  many  young  surgeons,  especially  my 
former  fellow-workers  in  India,  where  unrivalled  opportunities 
abound  for  the  practice  of  litholapaxy,  that  my  writings  have 
been  of  some  practical  aid  to  them  in  commencing  this 
operation. 

46,  Harley  Street,  London. 
May,  1896. 


CONTENTS 


CHAPTER  PAGE 

I.   INTRODUCTORY     -------  9 

II.    THE   INSTRUMENTS   EMPLOYED   IN   LITHOLAPAXY  -                 -                 -  14 

III.  THE   OPERATION    OF   LITHOLAPAXY                -                 -                 -                 -  37 

IV.  THE  author's  EXPERIENCE   OF  THE   OPERATION,  WITH  COGNATE 

STATISTICS        -                 -                 -                 -                 -                 -                 -  54 

V.    DIFFICULTIES    AND    COMPLICATIONS    MET    WITH  :     ILLUSTRATIVE 

CASES  --------  62 

VI.    LITHOLAPAXY   IN    MALE    CHILDREN   AND    IN   FEMALES          -                 -  79 

VII.    INTERESTING   CASES,    WITH    PRACTICAL    OBSERVATIONS      -                 -  92 

VIII.    SMALL    CALCULI  :     THEIR     DIAGNOSIS    AND     REMOVAL.      WHAT     IS 

A   STONE   IN    THE    BLADDER  ?    -                 -                 -                 -                 -  102 

IX.    CONCLUDING   REMARKS      -                 -                 -                 -                 -                 -  113 

INDEX       --------  119 


CHAPTEE  I. 

INTRODUCTORY. 

Some  eighteen  years  have  now  elapsed  smee  the  late  Professor 
H.  J.  Bigelow,  of  Harvard,  U.  S.  America,  startled  the 
medical  profession  by  the  introduction  of  his  new  operation 
for  stone  in  the  bladder.  This  operation,  which  he  named 
'  Litholapaxy,'  consisted  in  crushing  and  at  once  evacuating 
through  the  natural  passages,  at  one  sitting,  the  whole  of  the 
stone,  no  matter  how  large  and  hard,  provided  that  it  could  be 
caught  and  crushed  by  the  large  lithotrites  then  introduced. 
The  proposals  involved  in  this  operation  struck  at  the  roots 
of  all  our  most  cherished  tenets  regarding  the  removal  of 
stone  by  the  old  operation  of  lithotrity,  introduced  in  France 
by  Civiale,  and  practised  in  this  country  by  a  few  surgeons, 
but  chiefly  by  Sir  Henry  Thompson,  who  may  be  regarded  as 
the  apostle  of  the  old  operation,  and  through  the  advocacy 
and  practice  of  which  he  had  built  up  his  great  reputation. 

The  first  to  exhibit  Bigelow' s  mstruments  and  demonstrate 
his  operation  in  this  country  was  Mr.  Eeginald  Harrison,  at 
the  meeting  of  the  British  Medical  Association  in  1878. 
Harrison,  who  had  witnessed  Bigelow  operate  in  America, 
thought  well  of  the  new  operation,  which,  however,  did  not 
receive  a  very  cordial  reception  from  the  medical  profession  or 
press  in  England. 

The  attitude  with  which  Sir  Henry  Thompson  received  the 
new  proposal  at  the  outset ;    the  ridicule  heaped  by  him  on 


lo  INTRODUCTORY 

Bigelow's  instruments  ;  his  subsequent  attempts,  on  finding 
the  operation  a  successful  one,  to  show  that  there  was  nothing 
new  in  it,  in  fact  that  he  himself  had  been  leading  up  to  it, 
even  doing  it,  for  years — thus  detracting  from  the  reputation 
of  an  American  brother — are  now  matters  of  history,  and 
redound  neither  to  the  foresight  nor  generosity  of  British 
surgery. 

Now,  everyone  who  knows  anything  about  the  history  of 
lithotrity  must  be  aware  that  previous  to  the  appearance  of 
Bigelow  on  the  scene,  in  1878,  the  tendency  of  all  lithotritists 
was  (1)  to  restrict  to  the  lowest  possible  limit  the  time 
occupied  at  each  sitting,  four  or  five  minutes  being  the 
utmost  time  allowed  as  safe  ;  (2)  to  employ  instruments  of 
the  smallest  size  possible  ;  and  (3)  to  leave  the  evacuation  of 
the  fragments  as  much  as  possible  to  natural  efforts.  The 
principles  on  which  this  practice  was  founded  were  :  (1)  That 
the  bladder  was  extremely  intolerant  of  the  presence  of 
instruments  ;  and  (2)  that  in  direct  proportion  with  the  length 
of  time  instruments  were  manipulated  there  was  the  prospect 
of  evil  consequences  resulting.  There  can  be  no  doubt  as  to 
the  teaching  that  prevailed  on  the  subject.  A  reference  to 
the  latest  editions  of  all  the  ordinary  text-books  published 
prior  to  1879  will  show  that  the  authors  were  unanimous  on 
these  points;  and  there  was  no  one  who  inculcated  the 
principles  and  practice  referred  to  more  strongly  than  Sir 
Henry  Thompson  himself,  as  might  be  illustrated  by  numerous 
extracts  from  his  writings.  It  was  reserved  for  Professor 
Bigelow  to  show  that  these  principles  were  altogether  wrong, 
and  to  introduce  a  practice  entirely  at  variance  with  the  old 
proceeding.  The  hypotheses  on  which  the  new  operation  was 
based  were  :  (1)  That  the  bladder  was  much  more  tolerant  of 
prolonged  manipulation  than  was  previously  supposed,  and 
(2)  that  the  temporary  manipulation  of  blunt  and  polished 
instruments   in    the    bladder   was    less    irritating    than   the 


INTRODUCTORY  n 

continued  presence  in  the  organ  of  sharp  fragments  of 
calcukis.  For  the  purpose  of  working  out  his  idea  Bigelow 
introduced  larger  lithotrites  than  had  previously  been  used, 
and  invented  an  entirely  new  evacuating  apparatus  by  which 
debris  might  be  rapidly  extracted  from  the  bladder.  In  the 
introduction  of  the  large  evacuating  cannulas,  Bigelow  availed 
himself  of  the  discovery  of  Otis,  that  the  urethra  is  much 
more  capacious  than  was  previously  recognized. 

My  own  lines  were  at  that  time  cast  in  India,  where  ample 
opportunities  were  available  for  putting  the  new  operation  to 
the  test.  Lithotrity  had  never  become  popular  in  that 
country,  owing  partly  to  the  aversion  with  which  Orientals 
regard  any  method  of  treatment  that  involves  several  distinct 
surgical  proceedings,  extending  over  an  indefinite  period.  As 
with  many  of  my  professional  brethren  in  India,  lithotomy  in 
my  hands  had  proved  a  fairly  successful  operation.  I  did 
not,  therefore,  at  first  abandon  the  cutting  for  the  new 
operation.  I  must  confess,  however,  that  the  main  cause  of 
my  hesitation  in  adopting  the  new  operation  was  the  de- 
precative manner  in  which  it  was  criticised  by  Sir  Henry 
Thompson  on  its  introduction.  I  need  scarcely  say  that 
English  surgeons  had  been  in  the  habit  of  receiving  as  almost 
equivalent  to  divine  law  the  utterances  of  that  distinguished 
surgeon  on  any  point  connected  with  the  surgery  of  the 
urinary  organs.  When,  therefore,  I  read  of  the  '  disastrous  ' 
results  that  he  anticipated  from  Bigelow' s  operation,  I 
naturally  hesitated  in  adopting  it.  And  it  was  not  till  I  had 
subsequently  read  of  the  excellent  results  Sir  Henry  himself 
had  obtained  from  that  operation,  with  reference  to  which  he 
had  uttered  such  gloomy  forebodings,  that  I  finally  decided  on 
giving  the  operation  a  trial. 

Shortly  after  I  gave  expression  to  this  fact  in  the  Lancet, 
I  was  favoured  by  a  very  friendly  letter  from  Sir  Henry 
Thompson,  in  the  course  of  which,  referring  to  my  article  in 


12  INTRODUCTORY 

that  journal,  he  says  :  '  I  felt  much  pained  at  your  belief  that 
I  had  opposed  the  operation  at  the  outset,  or  foretold  it  wo  aid 
be  "  disastrous."  All  I  can  say  is  that  I  have  no  recollection 
of  having  done  so.'  And  again  :  '  I  expressed  my  dislike  to 
Bigelow's  instruments,  a  dislike  I  still  maintain;  but  his 
method  I  have  never  opposed,  and,  since  trying,  have  never 
failed  to  espouse  and  to  praise.' 

Now,  I  should  be  extremely  sorry  to  misrepresent  Sir  Henry 
Thompson,  but,  after  a  re-perusal  of  his  utterances  on  the 
subject,  I  must  say  that  his  writings,  which  on  other  subjects 
are  so  lucid,  on  this  render  him  liable  to  misinterpretation. 
I  shall  reproduce  later  on  the  quotations  from  Sir  Henry 
Thompson's  writings  above  alluded  to,  and  the  reader  will 
have  an  opportunity  of  judging  for  himself  the  meaning  they 
convey. 

As  soon  as  I  could  procure  the  necessary  instruments  from 
England,  I  commenced  at  once,  in  1882,  to  give  the  new 
operation  a  fair  and  unprejudiced  trial,  and  in  1885  published 
in  the  Lancet*  full  details  of  my  first  111  cases.  In  that 
paper  I  challenged  the  position  assumed  by  Sir  Henry 
Thompson  with  reference  to  Bigelow's  operation,  and  I 
venture  to  say  that  the  results  obtained,  from  what  was  at 
the  time  a  comparatively  large  number  of  operations  by  this 
method,  put  an  end  once  and  for  all  to  those  theoretical 
objections  and  gloomy  forecasts  put  forward  by  surgeons 
brought  up  in  the  prejudices  of  the  old  school  of  lithotrity. 

My  experience  of  Bigelow's  operation  now  extends  to  610 
cases,  and  to  864  operations  for  stone  in  the  bladder  by  all 
methods,  and  so  satisfied  am  I  with  the  results  obtained  that, 
as  will  be  seen  later  on,  I  have  now  practically  abandoned  all 
other  methods  in  favour  of  Bigelow's.  In  recording  my  cases, 
it  has  been  my  custom  to  jot  down  in  my  note-books  any 
observations  or  reflections  of  a  practical  character  that 
*  February  28,  March  7  and  14. 


INTRODUCTORY  13 

occurred  to  me  at  the  time  of  operating,  and  it  is  from  these 
notes  that  the  following  pages  are  mamly  built  up.  No 
practice  is  here  advised  and  no  principle  inculcated  that 
has  not  been  fully  subjected  to  the  test  of  my  own  ex- 
perience. It  is  hoped  that  the  illustrative  cases  given  in 
detail,  dealing  with  the  various  difficulties  and  complications 
met  with  in  this  operation,  will  be  particularly  useful  to 
surgeons  commencing  this  branch  of  surgery. 


CHAPTEE  II. 

THE  INSTRUMENTS  EMPLOYED  IN  LITHOLAPAXY. 

To  appreciate  fully  the  great  revolution  in  the  surgery  of  the 
bladder  involved  in  Bigelow's  operation,  it  will  be  necessary 
to  give  a  brief  sketch  of  the  history  of  lithotrity,  and  this  will 
involve  a  description  of  the  development  of  one  of  the  essential 
instruments  of  the  modern  operation — viz.,  the  lithotrite. 

Though  cutting  operations  of  various  kinds  for  stone  have 
been  practised  from  the  earliest  ages,  it  was  not  till  the 
beginning  of  the  present  century  that  the  idea  of  removing  a 
stone  by  pulverizing  it  within  the  bladder,  and  allowing  the 
ddbris  to  escape  by  the  natural  passages,  was  entertained. 
The  first  to  crush  a  stone  on  scientific  principles  was  the  great 
French  surgeon  Civiale,  in  1824.  This  he  effected  by  the 
'  trilabe,'  a  species  of  drill  consisting  of  a  central  axis  and 
three  claws,  which,  after  introduction  of  the  instrument  into 
the  bladder  through  the  urethra,  were  made  to  project  and 
catch  the  stone.  The  reduction  of  the  stone  to  fragments  was 
effected  by  drilling  holes  in  it  in  various  directions  till  it 
crumbled  into  debris.  The  operation,  which  he  named 
'  lithotrity,'  extended  over  several  sittings,  the  fragments 
passing  away  naturally  with  the  urine.  It  will  be  observed 
that  the  disintegration  of  the  stone  was  accomplished  by  a 
drilling  rather  than  by  a  crushing  process.  Shortly  after- 
wards a  great  improvement  was  effected  by  Weiss,  of  London. 


THE  INSTRUMENTS  EMPLOYED  IN  LITHOLAPAXY    15 

He  constructed  an  instrument  by  which  the  stone  was  grasped 
between  two  short  blades,  bent  at  an  angle  with  the  shaft,  and 
reduced  to  fragments  by  a  true  crushing  process.  And,  though 
various  improvements  have  since  been  effected,  it  may  be  said 
that  this  is  the  model  on  which  all  modern  lithotrites  are 
constructed. 

In  the  development  of  the  lithotrite,  various  changes  have 
been  made  in  the  method  of  applying  the  motive  power  by 
which  the  stone  is  crushed  between  the  blades.  Thus,  in 
Heurteloup's  time,  the  patient  was  placed  in  a  peculiar- 
shaped  bed,  to  which  a  vice  was  attached.  After  the  lithotrite 
was  introduced  into  the  bladder,  and  the  stone  grasped  between 
its  jaws,  it  was  fixed  in  the  vice,  and  the  stone  reduced  to 
debris  by  blows  of  a  hammer  applied  outside.  Some  time 
after,  a  great  improvement  was  effected,  in  the  introduction 
of  the  screwing  process  by  Hodgson,  of  Birmingham.  Sir 
William  Fergusson  advocated  the  rack-and-pinion  system  in 
the  lithotrite,  but  the  screwing  process  is  that  generally  now 
adopted.  Lastly,  Sir  Henry  Thompson  adapted  the  cylin- 
drical handle  to  the  lithotrite ;  and  this,  combined  with 
Weiss's  method,  by  which  the  sliding  action  may  be  con- 
verted into  a  screwing  one,  is  now  generally  employed  in  the 
construction  of  modern  lithotrites. 

Turning  aside  temporarily  from  the  instruments,  let  us 
glance  at  the  principles  involved  in  the  operation.  As  already 
mentioned,  Civiale's  practice  was  to  crush  small  quantities  of 
stone  at  repeated  sittings,  each  extending  over  a  few  minutes 
only,  the  detritus  coming  away  by  natural  efforts  with  the 
urine.  From  time  to  time,  however,  attempts  were  made  to 
assist  Nature  in  getting  rid  of  the  debris  by  artificial  means. 
For  this  purpose  currents  of  water,  injected  into  the  bladder 
through  a  large  catheter  from  a  syringe,  were  employed  by 
Heurteloup  and  others.  In  1846  Sir  Philip  Crampton,  of 
Dublin,    invented   a   suction    apparatus   resembling   a    large 


1 6     THE  INSTRUMENTS  EMPLOYED  IN  LITHOLAPAXY 


soda-water  bottle  with  a  tap  at  the  neck,  which  was  exhausted 
of  air,  and  then  applied  to  a  catheter  previously  introduced 
into  the  bladder,  and,  in  this  way,  an  attempt  made  to  get  rid 
of  the  fragments.  Subsequently,  Mr.  Clover  designed  his 
syringe  (Fig.  1),  which  consisted  of  an  indiarubber  bulb  with 
a  glass  receiver,  from  which  water  was 
pumped  into,  and  withdrawn  from,  the 
bladder  through  a  catheter.  No.  12  or 
13  ;  and  m  this  way  a  certain  quantity 
of  sand  was  brought  away.  Then,  again, 
Sir  "William  Fergusson  endeavoured  to 
complete  the  operation  at  one  sitting 
by  withdrawing  the  fragments  through 
the  urethra  by  means  of  long  and 
slender  lithotrites.  Sir  Henry  Thomp- 
son, though  apparently  adverse  to  this 
method  at  first,*  subsequently  employed 
it  for  a  time.t  But  it  came  to  be 
regarded  by  the  profession  as  a  very 
dangerous  process,  often  mflictmg 
severe  mjury  on  the  urethra. 

All  these  methods  of  artificial  evacua- 
tion of  debris  were  invented  with  a  view  to  obviate  the  recog- 
nized danger  of  allowing  rough  and  sharp  fragments  of  stone 
to  remain  in  the  bladder — a  common  cause  of  cj^stitis.  Each 
method  enjoyed  a  temporary,  though  transient,  notoriety ; 
but  they  one  and  all  fell  into  disrepute,  for  the  simple  reason 
that  they  failed  to  accomplish  the  object  at  which  they  aimed, 
and,  at  the  same  time,  caused  a  great  deal  of  irritation. 
And  the  practice  which  Civiale  had  inculcated — of  short  and 
frequent  sittings,  the  debris  being  allowed  to  come  away  by 


■■'•  '  Lectures  delivered  at  the   College  of  Surgeons,  England,  1884,'  by 
Sii-  H.  Thomi^son,  p.  117. 

t  '  Lithotrity  at  One  or  More  Sittings '  {Lancet,  vol.  i.,  1879,  p.  145). 


THE  INS  TR  UMENTS  EM  PL  O  YED  IN  LITHOLA  PAXY    17 


natural  efforts — came  eventually  to  be  recognized,  by  universal 
consensus  of  opinion  amongst  the  profession,  as  the  most  safe 
and  judicious. 

Such  was  the  position  of  lithotrity  in  1878, 
when  Bigelow  appeared  on  the  scene  with  his 
new  oi)eration,  and  proposed  to  revolutionize 
the  whole  system  by  crushing  and  evacuating 
the  stone  at  one  sitting,  no  matter  how  pro- 
longed, and  no  matter  how  large  the  stone 
might  be,  provided  only  that  it  was  capable 
of  being  grasped  and  crushed  by  the  large 
lithotrites  then  proposed. 

Bigelow's  operation  practically  resolves 
itself  into  two  proceedings — the  reduction  of 
the  stone  to  fragments,  and  the  evacuation 
of  the  debris  from  the  bladder. 

The  crushing  of  the  stone  is  accomplished 
by  means  of  lithotrites,  similar  to  those  em- 
ployed for  the  old  operation  of  lithotrity, 
except  that,  owing  to  the  increased  scope  of 
the  new  operation  in  dealing  with  large  and 
hard  calculi,  some  of  the  lithotrites  employed 
for  adults  are  constructed  much  larger  and 
stronger  than  those  formerly  in  use.  On  the 
other  hand,  owing  to  the  more  recent  ex- 
tension of  the  modern  operation  to  male 
children  of  the  most  tender  ages,  extremely 
small  and  slender  lithotrites  are  now  em- 
ployed. In  Fig.  2  is  illustrated  a  lithotrite 
constructed  on  the  well-known  model  of  Weiss 
and  Thompson.  It  possesses  the  cylindrical  handle  intro- 
duced by  Sir  Henry  Thompson,  which  (in  the  words  of  the 
inventor)  '  enables  you,  in  the  search  for  a  small  stone  or 
fragments,  to  execute  rapid  and  delicate  movements  which 

2 


Fig.  2. 


i8     THE  INSTRUMENTS  EMPLOYED  IN  LITHOLAPAXY 

would  be  impossible  in  an  instrument  without  the  cylindrical 
handle.'  It  also  possesses  the  new  mode  of  changing  sliding 
into  screwing  action,  and  vice  versa,  introduced  by  Weiss. 
When  the  small  button  in  front  of  the  cylinder  is  pushed  back 
into  the  position  indicated  in  the  illustration,  the  instrument 
is  'locked,'  and  then  the  male  blade  moves  within  the  female 
blade  by  a  screwing  action  only;  but  when  the  button  is 
pushed  forward  m  the  direction  of  the  blades,  the  instrument 


is  *  unlocked,'  and  the  screwing  is  converted  into  a  sliding 
action. 

For  the  operation  of  litholapaxy,  three  varieties  of  this 
instrument  are  commonly  employed  :  (1)  A  fully  fenestrated 
lithotrite  (Fig.  3)  for  crushing  large  and  hard  stones.  The 
male  blade,  which  is  deeply  serrated  or  toothed,  passes 
through  the  female  blade,   driving  the   ddbris   through  the 


THE  INSTRUMENTS  EMPLOYED  IN  LITHOLAPAXY      19 

opening  in  the  latter,  or  tossing  it  away  on  either  side,  so  that 
no  blocking  of  the  blades  by  fragments  can  occur.  (2)  A 
flat-bladed,  non-fenestrated  lithotrite  (Figs.  4,  5),  which  is 
used  for  reducing  fragments  into  fine  powder,  after  the  coarse 
work  of  breaking  up  the  stone  has  been  effected  by  means  of 


Fig.  6. 


Fig,  7. 


the  fenestrated  instruments.  (3)  A  partially  fenestrated 
lithotrite  (Figs.  6,  7),  with  an  opening  in  the  heel  of  the 
female  blade,  used  for  the  same  purpose  as  the  latter,  and 
also  to  crush  small  and  medium  sized  calculi. 

For  some  years  after  I  began  to  practise  litholapaxy  I  used 
these   non-fenestrated   and   partially-fenestrated  instruments 


20     THE  INSTRUMENTS  EMPLOYED  IN  LITHOLAPAXY 


Fig.  8. 


a  good  deal ;  but  I  gradually  came  to  abandon 
them,  and  now  use  none  but  fully-fenestrated 
lithotrites  in  my  practice.  I  consider  the  use 
of  any  other  kind  unnecessary,  and  almost 
unjustifiable,  considering  the  danger  that 
exists  of  debris  getting  impacted  in  the  jaws 
of  non-fenestrated  instruments,  an  accident 
which  cannot  occur  with  fully-fenestrated 
ones  when  j)roperly  used.  The  use  of  the 
lithotrite  in  the  modern  operation  is  to  crush, 
never  to  Jish  out,  the  fragments,  a  role  to 
which,  as  we  have  seen,  it  was  frequently 
consigned  in  the  old  operation  of  lithotrity. 
Indeed,  I  cannot  conceive  any  circumstances 
in  which  it  would  be  advisable  to  use  a  non- 
fenestrated lithotrite  in  the  modern  operation. 

Sir  Henry  Thompson  writes  :*  '  A  collateral 
advantage  of  this  flat-bladed  instrument  is, 
that  it  will  hold  a  good  deal  of  debris  without 
undue  augmentation  of  its  size,  so  that  not 
a  little  can  be  safely  brought  away  by  the 
urethra,  if  desired,  whenever  the  instrument 
is  withdrawn.'  In  writing  thus,  four  years 
after  Bigelow's  operation  was  introduced,  Sir 
Henry  evidently  confounds  the  old  and  new 
operations.  'We  should,'  as  Bigelow  says, 
'  distinctly  recognize  that  what  can  be  with- 
drawn in  a  lithotrite  could  come  better 
through  a  tube,  and  that  the  only  province  of 
the  lithotrite  should  be  to  pulverize,  or,  in- 
deed, merely  comminute,  and  not  to  evacuate.' 

In  Bigelow's  lithotrite  (Fig.  8),  the  cylin- 

*  '  Diseases  of^  Urinary  Organs,'  sixth  edition,  1882, 
p.  78. 


THE  INSTRUMENTS  EMPLOYED  IN  LITHOLAPAXY     21 


drical  handle  of  Thompson's  instrument  is  retained  for  the 
left  hand ;  but  for  the   wheel  for  the  right  hand  a  ball  is 
substituted.      This  is  an  undoubted  improvement,  affording 
a  much  firmer  purchase — a  point  of  great  importance  when 
dealing  with  a   large  and   hard   calculus.     But  the   special 
feature  of  Bigelow's  lithotrite  is  the  introduction  of  a  new 
mode  of  locking  the  instrument.     This  is  effected  simply  by 
a  quarter  rotation  of   the  right  wrist,  whilst  the  hands  are 
in  position,  without  any  displacement  of  the  fingers ;  whilst 
a   quarter   rotation   of   the   wrist   in    the   opposite   direction 
unlocks   the    instrument.     In    the   lithotrite   of    Weiss   and 
Thompson,  the  thumb  of  either  hand  has  to  be  disengaged  to 
move  the  button,  a  performance  which  tends  to  render  the 
lithotrite  in  the  bladder  unsteady  at  the  critical  moment  of 
catching  the  stone.     By  the  ingenious 
device   of    Bigelow  this   objection   is 
obviated  —  a    decided    improvement. 
On  the  whole,  the  movements  of  this 
lithotrite  are  easier  and  more  graceful 
than  in  any  instrument  I  have  ever 
worked  with.    So  much  for  the  handle 
of  Bigelow's  lithotrite. 

I  cannot  say,  however,  that  I  like 
the  blades  of  this  instrument  nearly 
so  well  as  those  of  the  fenestrated 
lithotrites  by  Weiss  and  Thompson 
already  described.  '  The  blades  (Fig.  9) 
of  this  lithotrite  consist  of  a  shoe,  or 
female  blade,  the  sides  of  which  are 
so  low  that  a  fragment  falls  upon  it ; 

while  the  male  blade,  or  stamp,  offers  a  series  of  alternate 
triangular  notches,  by  whose  inclined  planes  the  detritus 
escapes  laterally  after  being  crushed  against  the  floor  and  rim 
of  the  shoe.     At  the  heel  of  the  shoe,  where  most  of  the  stone 


FULL   SIZE 


Fig.  9. 


22     THE  INSTRUMENTS  EMPLOYED  IN  LITHOLAPAXY 


is  usually  comminuted,  and  where  the  impact  is  therefore 
gi'eatest,  the  floor  is  high  and  discharges  itself  laterally,  while 
its  customary  slot  is  made  to  work  effectually '  (Bigelow) . 
The  blades  are  essentially  non-fenestrated,  and  liable  to  get 
clogged  with  debris,  as  I  have  frequently  found  m 
practice,  and,  therefore,  objectionable. 

In  1886  I  had  constructed  for  me  by  Weiss  a 
lithotrite  (Fig.  10),  in  which  the  handle  and 
lockmg  action  of  Bigelow  are  combmed  with  the 
fenestrated  blades  of  Weiss  and  Thompson.  The 
female  blade  is  completely  fenestrated,  the  male 
I  blade  passing  right  through  the  female  blade,  so 
4  that  when  closed  their  under  surfaces  are  flush  with 
each  other,  and  thus  all  fear  of  impaction  of  frag- 
ments is  avoided.  The  upper  edges  of  the  female 
blade  are  smooth,  and  bevelled  on  their  inner 
aspect,  so  that  there  is  much  less  chance,  even  m 
unpractised  hands,  of  the  mucous  membrane  of  the 
bladder  getting  nipped  between  the  blades  than  in 
those  Hthotrites  in  which  the  upper  edges  of  the 
female  blade  are  toothed.  Ten  years'  acquaintance 
with  this  lithotrite  enables  me  to  say  that  it  is 
practically  perfect  in  its  working  ;  and  it  is  the 
model  on  which  my  lithotrites  have  since  been 
constructed. 

Fig.  11  represents  a  lithotrite  which  Harrison 
has  recently  had  constructed,  in  which  both  the 
wheel-  and  ball-handles  are  replaced  by  a  curved 
and  flat  crossbar,  like  the  handle  of  a  corkscrew. 
The  locking-action  used  by  Guyon  and  French 
surgeons  generally  is  also  mtroduced.  I  have  no 
personal  experience  of  this  instrument,  but  I  have  seen  my 
friend  Mr.  Harrison  work  with  it,  and  he  tells  me  that  he 


Fig.  10. 


THE  INSTRUMENTS  EMPLOYED  IN  LITHOLAPAXY     23 


finds  this  crossbar  a  great  relief 
to  the  hand,  particularly  when 
dealing  with  large  calculi. 

The  second  object  aimed  at 
in  the  operation — the  removal 
of  the  debris  from  the  bladder 
— is  accomplished  by  means  of 
large  cylindrical  tubes,  or  eva- 
cuating catheters,  introduced 
through  the  urethra,  and  an 
aspirator,  or  suction  apparatus, 
attached  thereto. 

Some  time  before  the  intro- 
duction of  Bigelow's  operation, 
it  had  been  demonstrated  by 
Otis,  of  New  York,  that  the 
urethra  in  the  adult  male  is 
much  more  capacious  than  had 
previously  been  imagined  ;  and 
this  discovery  undoubtedly 
paved  the  way  towards  the  de- 
velopment of  the  new  operation. 
The  cannulse  employed  vary  in 
size  according  to  the  capacity 
of  the  urethra,  Nos.  6  to  11, 
English  scale,  being  used  for 
male  children,  and  Nos.  I'i  to  20 
for  adults  and  females  of  all 
ages.  In  my  own  practice  I 
have  not  found  it  necessary  to 
use  a  larger  cannula  than  No.  18 ; 

and  through  a  tube  of  this  calibre  I  have  removed  the  debris 
of  a  calculus  weighing  6^  ounces.  I  have,  however,  met 
with  cases  in  which  a  No.  19  or  20  cannula  might  have  been 


Fig.  11. 


24     THE  INSTRUMENTS  EMPLOYED  IN  LITHOLAPAXY 

passed  with  facility.  Cannula  are  made  of  thin  silver,  and 
vary  in  shape,  some  being  straight,  and  some  slightly  curved 
at  the  extremity  (Figs.  12,  13).  The  latter  I  prefer,  as  I  find 
them  more  easy  of  introduction.  The  orifice,  or  eye,  should 
be  large  enough  to  admit  any  fragment  that  will  pass  through 


II 


'/3  &ChLE 

Fig.  12. 


o 

Fig.  13. 


the  tube.     The  cannulse  should  be  armed  with  stylets  (Fig.  13), 
for  reasons  that  will  appear  later  on. 

Though  the  evacuating  catheters  remain  much  the  same 
now  as  on  their  introduction  by  the  originator,  several  modifi- 
cations have  been  effected  in  the  aspirator ;  and  these  I  shall 


THE  INSTRUMENTS  EMPLOYED  IN  LITHOLAPAXY    25 

now  describe,  indicating  the  varieties  of  aspirator  that  I  have 
found  most  effective. 

The  original  aspirator  of  Bigelow  is  represented  in  Fig.  14. 
It  consists  of  an  elastic  bulb  or  central  portion,  to  the  lower 
extremity  of  which  is  attached  a  removable  cylindrical  glass 
receiver  ;  whilst  from  its  upper  part  passes  an  indiarubber 


Fig.  15. 
tube,  the  end  of  which  fits  on  to  the  evacuating  catheter  pre- 
viously introduced  into  the  bladder.  The  apparatus,  pre- 
viously filled  with  water,  acts  as  a  kind  of  syphon.  By 
alternate  compression  and  expansion  of  the  bulb,  the  water  is 
pumped  into,  and  withdrawn  from,  the  bladder,  and  the  debris, 
which  is  carried  back  into  the  aspirator,  falls  down  into  the 
glass  receiver,  and  is  there  retained. 


26     THE  INSTRUMENTS  EMPLOYED  IN  LITHOLAPAXY 

The  next  form  of  Bigelow's  aspirator  is  represented  in 
Fig.  15,  to  which  is  added  an  elastic  tube  or  hose,  provided 
with  a  stop-cock  close  to  its  junction  with  the  bulb.  By  this 
hose  water  can  be  introduced  into  the  aspirator  from  a  neigh- 


FiG.  16. 

bouring  vessel  without  disturbing  the  apparatus.      There  is 
also  an  extra  stop-cock  for  the  evacuating  catheter. 

In  Bigelow's  more  recent  aspirator  (Fig.  16),  the  long 
flexible  elastic  tube  intervening  between  the  bulb  and  the 
evacuating  catheter  is  dispensed  with,  the  catheter  fitting  into 
a  brass  tube,  provided  with  a  tap,  inserted  into  the  side  of  the 
bulb  near   the   glass   receiver.      The   distance   between  the 


THE  INSTRUMENTS  EMPLOYED  IN  LITHOLAPAXY     27 


bladder  and  the  aspirator  is  thus  much  shortened.  At  the 
upper  part  of  the  bulb  is  a  tap  by  which  air  escapes,  and  is 
excluded  from  the  apparatus  when  filled  with  water.  A 
feature  of  the  new  aspirator  was  the  introduction  of  a  strainer 
(not  shown  in  the  woodcut)  for  preventing  the  return  of  debris 
from  the  receiver  into  the  bladder.  This  strainer  was  formed 
by  a  prolongation  within  the 
bulb  of  the  brass  tube, 
which  fits  on  to  the  catheter, 
in  the  form  of  a  perforated 
cylinder. 

In  practice  I  soon  found 
that  the  extra  stop-cock 
and  hose  were  not  essential, 
and  that  the  rough  surface 
of  the  perforated  strainer 
impeded  the  free  flow  of 
debris  from  the  bladder 
into  the  receiver.  In  fact, 
the  strainer  in  this  form 
of  aspirator  is  superfluous, 
as  fragments  of  stone  that 
once  pass  mto  the  receiver 
cannot  return  into  the 
bladder.  These  append- 
ages are  dispensed  with  in  the  modification  of  Bigelow's 
aspirator  represented  in  Fig.  17,  with  which  I  have  worked 
for  several  years,  and  which  is  thoroughly  efficient  in  all 
respects. 

I  have  recently  had  this  latter  aspirator  simplified  still 
fm-ther  by  dispensing  with  the  tap  above  the  rubber  bulb, 
which  is  not  really  necessary,  as  the  apparatus  can  be  easily 
filled  through  the  front  tap,  to  which  the  cannula  fits.  This 
may  be  effected  still  more  rapidly  by  removing  this  tap,  which 


Fig.  17. 


28     THE  INSTRUMENTS  EMPLOYED  IN  LITHOLAPAXY 


fits  on  to  the  bulb  by  means  of  a  bayonet- joint,  filling  the 
apparatus  with  the  fluid,  replacing  the  tap,  and  then  pouring 
in  a  little  more  fluid  to  completely  exclude  air  before  closing 
the    tap.     This    (Fig.   18)    I  ^ 

now    consider    the    simplest,  !^^^  # 

handiest,  and  most  practical 
modification  of  Bigelow's  aspi- 
rator yet  introduced ;  and  it 
has  the  additional  advan- 
tage of  being  comparatively 
moderate  in  cost. 

We  now  come  to  the  modi- 
fications of  Bigelow's  aspirator 


Fig.  18. 


Fig.  19. 


used  by  Sir  Henry  Thompson,  of  which  there  are  no  less  than 
four. 

The  earliest  variety  (Fig.  19)  consists  of  a  stout  indiarubber 
bottle,  on  the  upper  part  of  which  is  a  tap,  and  above  this  a 
small  funnel  through  which  the  bottle  is  to  be  filled.  At  the 
lower  end  is  a  brass  tube,  attached  to  which  are  the  lower  tap 


THE  INSTRUMENTS  EMPLOYED  IN  LITHOLAPAXY     29 


and  the  glass  receiver.  The  evacuatuig  catheter  is  appUed  to 
the  metal  tube  opposite  the  tap.  The  brass  tube,  to  which  the 
glass-  receiver  is  attached  by  a  bayonet-johat  or  screw,  is  con- 
tinued down  a  short  way  into  the  glass  globe,  thus  acting 
as  a  trap  to  prevent  the  return  of  the  fragments  from  the 
receiver. 

In  the  aspirator  just  described,  the  glass  receiver  is  placed 

directly  beneath  the 
indiarubber  bulb,  and 
it  is  found  in  practice 
that  the  debris  in  the 
receiver  is  disturbed  by 
the  currents  of  water 
produced  by  the  alter- 
nate compression  and 
expansion  of  the  bulb. 
Some  of  the  debris 
passes  back  into  the 
bulb,  and  from  there  a 
portion  is  carried  again 
into  the  bladder  by  the 
return  stream. 

To  obviate  this,  Weiss 
suggested  that  the  brass 
cylinder  with  glass  re- 
ceiver be  removed  to  the 
front  of  the  indiarubber 
bulb  (Fig.  20),  in  which  position  its  contents  would  be  less 
influenced  by  the  currents  passing  over  the  mouth  of  the 
receiver.  When  the  aspirator  is  in  action,  the  greater  portion 
of  the  debris  falls  down  into  the  receiver,  as  the  stream  from 
the  bladder,  diminished  in  force,  passes  the  empty  chamber 
over  its  mouth.  Some,  however,  enters  the  bulb,  and  is 
carried  back  again  with  the  reverse  stream  ;  but  the  catheter- 


FiG.  20. 


30     THE  INSTRUMENTS  EMPLOYED  IN  LITHOLAPAXY 

opening  in  the  cylindrical  chamber  being  much  smaller  than 
the  opening  into  the  bulb,  most  of  the  fragments  impinge 
against  the  sides  and  front  of  the  cylindrical  chamber,  and 
fall  down  into  the  receiver.  Still,  a  little  debris  does  pass 
back  into  the  bladder,  to  be  again  withdrawn.  Now,  as 
Bigelow  remarks  :*  "We  may  fairly  assume  that  a  surgeon 
would  not  deliberately  inject  foreign  bodies  into  a  patient's 
bladder,  so  there  must  be  something  wrong  in  a  system  which 
obliges  him  to  do  this,  and  makes  it  necessary  to  aspirate  the 
same  debris  twenty  times  over  in  order  to  remove  it.  In 
short,  the  apparatus,  as  commonly  arranged,  is  still  a  defective 
one,  and  needs  some  special  contrivance  to  assist  the  action  of 
gravity  in  securing  the  debris."  Admitting  the  force  of  these 
remarks,  the  objection  raised  is  to  a  certain  extent  theoretical. 
I  have  worked  with  this  variety  of  aspirator  a  great  deal,  and 
have  found  it  efficient.  The  great  drawback  to  this  aspirator 
is  that  a  large  proportion  of  the  debris,  instead  of  falling  down 
into  the  glass  receiver,  passes  back  into  the  indiarubber  bag, 
so  that  one  may  be  deceived  as  to  the  amount  of  debris 
extracted. 

In  Figs.  21,  22  are  illustrated  Sir  Henry  Thompson's  most 
recent  forms  of  aspirator.  In  the  first  of  these,  for  the  brass 
cylindrical  chamber  and  globular  glass  receiver  in  his  previous 
instruments  we  have  now  substituted  a  plain  glass  cylindrical 
receiver,  somewhat  resembling  the  glass  trap  in  Clover's 
original  syringe.  A  special  feature  in  this  aspirator  is  the 
introduction  of  a  light  wire  valve,  attached  inside  the  chamber 
for  the  debris  to  the  tube  which  receives  the  evacuating 
catheter.  Its  action  is  thus  described  by  Sir  Henry  :  '  When 
pressure  is  made  on  the  indiarubber  globe,  and  the  current 
flows  by  the  evacuating  catheter  into  the  bladder,  this  light 
valve  is  driven  close  to  the  aperture,  and  no  debris  can  leave 
the  glass  trap.  When  pressure  is  removed,  and  the  current 
'•=  Lancet,  January  6, 1883,  p.  6. 


THE  INSTRUMENTS  EMPLOYED  IN  LITHOLAPAXY    31 

returns  from  the  bladder,  the  valve  floats  widely  open,  and 
permits  the  debris  to  enter  unchecked.' 


Fig.  21. 


Fig,  22. 


The  aspirator  pictured  in  Fig.  22  differs  from  the  latter  only 
in  the  shape  of  the  glass  receiver. 

These   two   recent   forms   of   aspirator,  which    Sir   Henry 


32     THE  INSTRUMENTS  EMPLOYED  IN  LITHOLAPAXY 


Thompson  says*  are  'not  far  removed  from  the  origmal 
pattern  of  Clover,'  are  not  nearly  so  efficient  as  his  previous 
one  (Fig.  20).  From  their  length  and  want  of  balance  they 
are  very  awkward  in  practice.  The  current  of  water  passes 
directly  into  the  receiver  and  disturbs  the  debris  lying  there, 

and  the  valve,  as  Sir 
Henry  himself  admits, 
'  is  sometimes  liable  to 
be  partially  blocked,  as 
when  mucus  and  fine 
debris  are  present.'  In 
fact,  a  previous  remark! 
of  Sir  Henry  Thompson, 
when  criticizing  Bige- 
low's  views  as  to  the  con- 
struction of  a  new  aspi- 
rator :  '  All  the  perfor- 
ated tubes  and  strainers 
get  so  blocked  with 
debris  (as  I  found  long 
since)  in  the  human 
body — not  with  coal  in 
water — as  to  be  practi- 
cally useless  there,' — is, 
to  a  large  extent,  appli- 
cable to  his  new  forms 
of  aspirator.  In  the 
desire  to  produce  an 
aspirator  resembling  the 
original  syringe  of 
Clover,  efficiency  is  sacrificed  to  appearance,  for  the  sake  of 
assigning  to  the  latter  apparatus  a  position  which  neither  the 

*  Lancet,  April  12,  1884,  p.  653.  t  -f&*^-.  vol.  i.,  1883. 


Fig.  23. 


THE  INSTRUMENTS  EMPLOYED  IN  LITHOLAPAXY     2,^^ 

inventor  nor  any  other  surgeon,  except  Sir  Henry  Thompson, 
has  claimed  for  it. 

I  have  almost    annually   for    several  years    past   spent   a 
portion  of  my  holidays  in  observing  the  surgical  work  done  in 


Fig.  24. 

the  Paris  hospitals,  and  particularly  the  surgery  of  the  genito- 
urinary organs  m  Professor  Guy  on' s  dinique  at  the  Necker 
Hospital.  No  one  has  a  greater  admiration  for  the  excellent 
work  done  by  Dr.  Guj'on  than  I  have.  I  was,  therefore,  much 
astonished  at  the  inefficiency  of  the  aspirator  (Fig.  23)  which 

3 


34 


THE  INSTRUMENTS  EMPLOYED  IN  LITHOLAPAXY 


bears  his  name.  It  will  be  observed  that  in  this  apparatus 
the  cannula,  when  applied,  forms  a  right  angle  with  the  tube 
carrying  the  lower  tap,  and  intervening  between  it  and  the 
body  of  the  aspirator.  This  tube  has  a  hollow  cylinder  of 
glass   let   in   between   two   portions   of    soft   rubber  tubing, 

through  which  the  debris  can 
be  seen  passing  from  the 
bladder.  Owing  to  the  sharp 
angle  between  the  cannula 
and  the  tube,  the  multiple 
composition  of  the  latter,  and 
the  length  of  the  stream,  the 
current  is  extremely  weak, 
and  incapable  of  extracting 
coarse  debris  from  the  bladder. 
Professor  Guyon,  however, 
depends  on  repeated  injec- 
tions of  water  from  large 
glass  syringes  through  the 
cannula  into  the  bladder  for 
the  removal  of  the  coarse 
debris,  which  flows  out  with 
the  return  stream ;  and  the 
aspirator  is  used  only  towards 
the  conclusion  of  the  opera- 
tion for  the  removal  of  fine 
ddbris. 

Mr.  J.  H.  Morgan,  of  Charing  Cross  Hospital,  has  designed 
an  aspirator  (Fig.  24)  which  is  light  and  handy.  I  have  not 
had  much  experience  of  this  apparatus,  but  Mr.  Morgan 
himself,  Mr.  Eeginald  Harrison  and  others  report  favourably 
of  it. 

Fig.  25  represents  Keegan's  aspirator  ;  I  have  never  had 
an  opportunity  of  ushag  it ;  but  Dr.  Keegan  tells  me  that  it  is 


Fig.  25. 


THE  INSTRUMENTS  EMPLOYED  IN  LITHOLAPAXY     35 


a  very  efficient  aspirator,  and  I  need  scarcely  say  that  no 
higher  authority  on  the  subject  exists. 

The    aspirators    designed    by  Goldmg-Bird   and   Otis   are 


Fig.  26. 


Fig.  27. 


represented   in   Figs.    26   and   27    respectively,    and   do  not 
requh'e  further  description. 

Such,  then,  are  the  chief  varieties  of  aspirator  before  the 

profession.      There  are  many  others,  which  it  will   be  un- 


36     THE  INSTRUMENTS  EMPLOYED  IN  LITHOLAPAXY 

necessary  to  refer  to  here.  In  fact,  there  are  few  surgeons  of 
repute  who  practise  litholapaxy  who  have  not  designed 
aspirators  to  suit  their  own  pecuHar  views.  But  they  are,  one 
and  all,  modified  imitations  of  Bigelow's  original  instrument. 
All  those  described  are  efficient  evacuators  ;  but  the  most 
convenient  and  effective  are,  in  my  opinion,  those  represented 
in  Figs.  17  and  18. 


CHAPTER  III. 

THE  OPERATION  OF  LITHOLAPAXY. 

Having  in  the  previous  chapter  given  a  sketch  of  the  special 
instruments  employed  in  the  operation  of  litholapaxy,  I  will 
now  proceed  to  describe  in  detail  the  various  stages  of  the 
operation.  I  will  assume  that  a  stone  of  moderate  size  has 
been  diagnosed  in  an  adult,  and  its  presence  confirmed  by  the 
sound. 

It  will  be  well  in  all  cases  to  submit  the  patient  to  prelimi- 
nary treatment  for  a  few  days  previous  to  undertaking  the 
operation.  The  patient  should  be  put  to  bed  and  placed  on  a 
light,  nourishing  diet.  The  bowels  should  be  regulated,  a 
purgative,  such  as  castor-oil,  being  given  should  constipation 
exist,  and  mild  astringents  should  the  patient  suffer  from 
diarrhoea,  which  is  often  the  case.  Barley-water,  with 
alkalies  and  tincture  of  hyoscyamus,  should  be  given  if  there 
be  much  irritation  of  the  bladder  with  acidity  of  the  urine. 

For  the  operation,  I  find  a  low,  narrow  operating-table  the 
most  convenient.  The  patient  is  placed  on  this,  close  to  the 
right  edge,  with  his  head  resting  on  a  pillow.  The  buttocks 
are  raised  by  means  of  a  low  cushion  placed  beneath  them. 
This  is  an  important  point,  as  the  stone  thus  gravitates  to  the 
base  of  the  bladder,  away  from  the  neck,  and  renders  the 
latter  part,  which  is  the  most  sensitive,  less  likely  to  be 
injured  in  the  various  manipulations.     The  legs  and  thighs 


38  THE  OPERATION  OF  LITHOLAPAXY 

are  flexed  and  slightly  abducted,  and  held  in  this  position  by 
an  assistant  on  either  side. 

In  the  cold  weather  it  is  very  essential  that  the  patient 
should  be  protected  by  warm  clothing  during  the  operation,  to 
prevent  chill.  For  this  purpose  a  pair  of  large  woollen 
stockings  should  be  slipped  on,  reaching  right  up  the  thighs 
close  to  the  groins.  Such  a  pair  of  stockings  can  be  made 
loosely  out  of  an  old  blanket.  In  addition  to  the  ordinary 
clothing,  a  light  blanket  should  be  thrown  over  the  chest. 

Close  to  the  operator's  right  hand  should  be  placed  a  small 
stand,  or  table,  with  a  tray  or  basin  containing  warm  carbolic 
lotion,  in  which  the  lithotrites  and  evacuating  catheters 
should  be  placed  ready  for  use ;  while  the  aspirator,  pre- 
viously filled  with  warm  water,  should  be  entrusted  to  an 
assistant  conversant  with  its  working.  It  is  well,  when 
possible,  to  have  two  aspirators  ready  at  hand,  to  be  used 
alternately.  The  operation  is  thus  facilitated,  as,  while  the 
surgeon  is  using  one,  the  second  can  be  emptied  of  debris 
and  refilled  with  water  by  the  assistant. 

A  small  cup  containmg  oil  should  be  at  hand  for  lubricating 
the  instruments.  In  this  operation  too  much  oil  cannot  be 
used,  the  instruments  being  well  lubricated  at  each  intro- 
duction. 

Before  undertaking  the  operation  of  litholapaxy  the  surgeon 
must  learn  to  pass  all  instruments — lithotrites,  sounds,  and 
catheters — on  the  right  side.  This  requires  only  a  little 
practice  to  do  it  with  ease,  and  much  time  is  saved  thereby. 
Besides  the  loss  of  time  involved,  it  is  extremely  awkward  to 
see  a  surgeon  passing  the  instruments  on  the  patient's  left 
side,  and  then  going  round  to  the  right  side  to  use  them. 

The  patient  now  being,  as  a  rule,  anaesthetized,  the  surgeon, 
standing  on  his  right  side,  should  first  pass  a  large  conical 
steel  sound  into  the  bladder. 

A  series  of  highly-polished  sounds  of  this  kind  (Fig.  28), 


THE  OPERATION  OF  LITHOLAPAXY 


39 


from  No.  6  to  18,  should  be  at  hand.  They  should  be  made 
slightly  tapering  at  the  point,  so  that  the  diameter  there  is 
two  sizes  smaller  than  higher  up  at  the  bend.  Solid  heavy 
sounds  of  this  kmd  are  easily  passed,  and  are 
handy  for  ascertainmg  the  capacity  of  the 
urethra,  and  for  facilitating  the  passage  of 
other  instruments.  It  will  frequently  be 
found  that,  when  neither  a  catheter  nor  a 
lithotrite  will  pass  into  the  bladder,  a  heavy 
sound  of  this  shape  will ;  and  on  its  with- 
drawal the  lithotrite  or  cannula  may  be 
slipped  in. 

The  meatus  is,  as  a  rule,  the  narrowest  part 
of  the  urethra,  and  it  will  frequently  be  found 
necessary,  in  order  to  pass  the  large  instru- 
ments employed  in  litholapaxy,  to  enlarge 
it  slightly.  Should,  therefore,  a  large  sound 
not  pass,  this  must  be  done  at  once.  For 
this  purpose  a  director  is  introduced  into  the 
urethra,  and  the  floor  of  the  meatus  incised 
by  means  of  a  long  slender  scalpel.  Or  a 
urethrotome  may  be  employed  for  this  pur- 
pose. The  operation  is  a  very  harmless  one, 
and  frequently  procures  an  improvement  on 
Nature. 

The  question  now  arises  as  to  the  quantity 
of  water  the  bladder  should  contain  during 
the  crushing  of  the  stone.  As  a  rule,  a  very  small  quantity, 
from  one  to  three  or  four  ounces,  will  be  sufficient  to  protect 
the  walls  of  the  bladder,  and  at  the  same  time  permit  of  the 
necessary  movements  of  the  lithotrite.  A  large  quantity  of 
water  is  objectionable,  involving  an  increased  area  over  which 
the  fragments,  impelled  by  the  currents  set  up  by  the  move- 
ments of  the  lithotrite,  may  roam,  and  thus  increasing  the 


Fig. 


40  THE  OPERATION  OF  LITHOLAPAXY 

difficulty  in  catching  them.  If,  on  the  other  hand,  the 
bladder  be  completely  empty,  injury  to  its  walls  may  result 
from  the  lithotrite.  For  my  own  part,  I  am  indifferent  as  to 
the  quantity  of  water  the  bladder  may  contain,  provided  it  be 
not  too  large. 

The  lithotrite  is  now  introduced  thus  :  The  operator  stands 
obliquely,  with  his  left  side  towards  the  patient's  face.  The 
Athotrite,  previously  screwed  home,  locked  and  oiled,  is  held 
horizontally  in  the  right  hand  by  the  cylindrical  handle,  with 
the  beak  pointmg  downwards.  The  penis  is  grasped  between 
the  thumb  and  two  first  fingers  of  the  left  hand,  and  the  beak 
of  the  instrument  introduced  into  the  urethra,  the  penis  being 
drawn  slowly  but  steadily  on  to  the  lithotrite,  which  is 
gradually  elevated  till  it  reaches  the  perpendicular  position,  as 
it  slides  along  the  canal,  which  it  does  by  its  own  weight. 
The  beak  will  now  have  entered  the  membraneous  portion  of 
the  urethra  as  it  passes  through  the  triangular  ligament.  By 
gently  depressing  the  handle  of  the  lithotrite  in  the  middle 
line  towards  the  horizontal  position,  the  beak  will  be  found  to 
slip  along  the  membraneous  and  prostatic  portions  of  the 
urethra  and  mto  the  bladder.  As  Sir  Henry  Thompson  truly 
remarks  :  '  There  is  no  more  easy  instrument  to  pass  than  the 
lithotrite  with  proper  management.' 

The  lithotrite  being  thus  introduced,  the  next  stage  of  the 
proceedings  consists  in  catching  the  stone.  For  this  purpose 
the  lithotrite  is  passed  gently  onwards,  or,  rather,  allowed  to 
proceed  by  its  own  weight,  along  the  trigone,  till  it  reaches 
the  most  dependent  part  of  the  base  of  the  bladder,  on  which 
it  is  allowed  to  rest.  The  instrument  is  then  unlocked,  and 
the  blades  opened  by  withdrawing  the  male  blade  an  inch  or 
more,  accordmg  to  the  size  of  the  stone,  the  female  blade 
being  held  steadily  in  position  by  the  left  hand  on  the  cylin- 
drical handle.  The  blades  are  now  closed,  when,  frequently, 
the   stone  will   be  found  between  them.      The   lithotrite   is 


THE  OPERATION  OF  LITHOLAPAXY  41 

locked,  and  lifted  slightly  off  the  base  of  the  bladder,  and  the 
stone  crushed  by  screwing  the  male  blade  home.  The  instru- 
ment is  again  unlocked,  the  blades  opened  and  closed,  when  a 
fragment  will  be  caught,  and  crushed  as  before.  This  process 
is  to  be  repeated  several  times,  till  a  considerable  quantity  of 
fine  debris  is  made.  Sir  Henry  Thompson  compares  the 
finding  of  fragments  to  fishing  for  perch — where  one  is  found 
there  will  many  be  caught.  We  must  not  go  searching  about 
the  bladder  for  fragments  till  those  in  the  locality  in  which 
the  stone  is  first  found  are  disposed  of.  The  depression  in 
the  base  of  the  bladder,  caused  by  the  weight  of  the  lithotrite 
resting  on  it,  facilitates  the  stone,  and  subsequently  its  frag- 
ments, falling  on  to  the  female  blade.  Surgeon-Colonel  J. 
Eichardson,  before  whom  I  had  the  pleasure  of  operating  for 
the  first  time  many  years  ago,  writing  a  few  days  subsequently 
of  the  features  in  the  operation  that  astonished  him,  says  : 
'  The  next  was  the  apparent  ease  with  which  the  stone  first, 
and  afterwards  its  fragments,  tumbled  into  the  jaws  of  the 
instrument.  It  almost  seemed  as  though  they  were  anxious 
to  get  crushed.' 

Should  the  stone  not  be  found  by  the  manoeuvres  above 
indicated,  it  must  be  searched  for.  This  is  done  by  opening 
the  blades  of  the  lithotrite,  turning  them  at  an  angle  of 
45°  towards  the  right,  and  again  towards  the  left,  and  closing 
them  in  these  positions  respectively.  Should  the  stone  still 
evade  detection,  the  handle  of  the  lithotrite  must  be  depressed 
towards  the  horizontal  position  between  the  thighs,  pushed  an 
inch  or  so  towards  the  posterior  surface,  and  the  same 
manoeuvres  gone  through  in  that  position,  searching  centrally, 
right  and  left.  The  stone  will  probably  be  found  in  one  of 
these  positions,  but  sometimes  it  lies  immediately  behind  the 
prostate,  especially  when  that  gland  is  enlarged.  To  grasp 
the  stone  in  this  position  the  handle  of  the  lithotrite  should 
be  depressed  between  the  thighs,  and  turned  right  round  on 


42  THE  OPERATION  OF  LITHOLAPAXY 

its  axis,  so  that  the  heak  points  downwards  towards  the 
trigone,  but  should  not  touch  it.  The  blades  are  then  opened 
and  closed  as  before  in  this  position,  and  if  the  stone  lies 
there  it  will  be  secured.  In  fact,  the  surgeon  should  make  a 
mental  survey  of  the  whole  bladder,  and  institute  a  methodical 
search  of  every  part  of  it  till  the  calculus  is  found.  All  the 
movements  must  be  light  and  graceful,  and  care  taken  that 
the  mucous  membrane  is  neither  caught  between  the  blades 
nor  otherwise  injured.  In  whatever  position  found,  the  stone 
must  be  brought  to  the  centre  of  the  bladder  and  there 
disposed  of. 

Let  us  now  assume  that  the  stone,  or  a  portion  of  it  if  a 
large  one,  has  been  reduced  to  fine  debris.  Should  the 
stone  be  a  small  one — say,  from  a  few  grains  up  to  3  or  4 
drachms  in  weight — its  complete  pulverization  will  probably 
be  accomplished  before  the  lithotrite  is  withdrawn,  in  a  period 
varying  from  one  to  eight  or  ten  minutes.  But  should  the 
stone  be  a  large  one,  a  considerable  amount  of  crushing, 
lasting  over  ten  minutes  or  so,  must  be  effected  before  re- 
moving the  instrument.  Before  withdrawing  the  lithotrite,  it 
must  be  locked  and  the  blades  screwed  tightly  home,  so  as  to 
render  them  free  of  debris.  I  may  here  say  that  no  instru- 
ment should  be  withdrawn  from  the  bladder  till  quite  free  of 
fragments. 

The  evacuating  catheter,  armed  with  a  stylet,  should  now 
be  passed  into  the  bladder,  the  largest  size  that  the  capacity 
of  the  urethra  will  easily  admit  being  used.  As  soon  as  the 
stylet  is  withdrawn,  a  rush  of  water  and  debris  will  take  place, 
to  receive  which  a  small  tray  or  porringer  should  be  at  hand. 
The  experience  already  gained  in  passing  the  solid  sounds  and 
lithotrites  will  afford  a  rough  estimate  of  the  size  of  cannula 
that  the  urethra  will  admit. 

The  cannula  having  been  introduced  into  the  bladder,  the 
aspirator,  previously  filled  with  warm  water,  or  boric  solution, 


THE  OPERATION  OF  LITHOLAPAXY  43 

is  applied,  the  tap  turned  on,  and  aspiration  of  the  debris 
begun.  The  right  hand  grasjDS  the  bulb  of  the  aspirator,  by 
the  compression  and  expansion  of  which  water  is  injected  into, 
and  withdrawn  from,  the  bladder.  With  the  outward  stream 
the  fragments  are  carried,  and  are  seen  to  fall  down  into  the 
glass  receiver,  where  they  remain.  Should  the  stone  be  a 
small  one,  and  have  been  completely  crushed  at  the  first 
introduction  of  the  lithotrite,  it  will  be  found  that,  after  the 
aspiration  has  gone  on  for  a  time,  the  whole  of  the  debris  will 
have  passed  into  the  receiver.  But  if  the  stone  be  a  large  one, 
after  a  considerable  quantity  of  debris  has  entered  the  receiver, 
which  will  vary  with  the  amount  of  crushing  at  the  first  intro- 
duction of  the  lithotrite,  little  or  no  debris  returns  with  the 
outward  stream,  but  a  rattling  sound  takes  place,  due  to  the 
fragments  too  large  to  pass  out  being  carried  with  force  against 
the  eye  of  the  cannula. 

The  aspirator  is  then  removed,  the  cannula,  rearmed  with 
the  stylet,  is  withdrawn,  and  the  lithotrite  again  introduced 
for  the  purpose  of  crushing  more  fragments.  This  is  followed 
by  the  cannula  and  as]pirator  as  before.  This  process  may 
have  to  be  repeated  several  times,  according  to  the  size  of  the 
stone,  before  the  whole  of  the  debris  is  removed. 

Such,  then,  is  a  general  description  of  the  operation.  There 
are,  however,  difficulties  met  with  and  points  to  be  attended 
to,  to  which  I  wish  to  draw  attention  here. 

In  the  healthy  urethra  of  an  adult  there  are  only  two  situa- 
tions, as  a  rule,  where  difficulty  may  be  encountered  in  the 
passage  of  instruments — viz.,  at  the  triangular  ligament,  and 
at  the  neck  of  the  bladder.  The  instrument  (lithotrite  or 
cannula)  should  first  be  passed  as  far  as  it  will  go  in  the 
direction  of  the  anus,  thus  depressing  the  floor  of  the  urethra 
in  front  of  the  triangular  ligament.  '  Traction  on  the  penis 
next  effaces  this  depression,  and  adds  firmness  to  the  urethral 
walls ;  so  that,  if  the  instrument  be  withdrawn  a  little,  and  at 


44  THE  OPERATION  OF  LITHOLAPAXY 

the  same  time  guided  bj^  the  bony  arch  above,  it  can  be  coaxed 
without  difficulty  through  the  ligament  in  question — a  natural 
obstruction  which  physicians  often  mistake  for  a  stricture. 
The  obstruction  passed,  the  rest  of  the  canal  is  short,  and 
corresponds  with  the  axis  of  the  body'  (Bigelow). 

The  obstruction  sometimes  met  with  at  the  neck  of  the 
bladder  is  due  to  the  firm  lower  edge  of  the  inner  meatus. 
This  may  be  overcome  by  pushing  the  lithotrite  or  cannula 
gently  onwards  in  the  direction  of  the  axis  of  the  body,  im- 
parting to  it  a  slightly  rotary  motion  if  necessary. 

When  the  urethra  is  capacious,  and  large  evacuating 
catheters  can  be  j)assed,  as  in  the  great  majority  of  cases  in 
the  adult,  it  is  unnecessary  to  reduce  the  stone  to  fine  sand, 
as  coarse  debris  can  pass  through  these  tubes  into  the  aspirator, 
and  it  is  a  waste  of  time  to  reduce  the  debris  to  a  finer  con- 
sistence than  what  will  pass  through  the  cannula  with  facility. 

During  the  earlier  part  of  the  process  of  aspiration,  the  end 
of  the  cannula  should  be  kept  towards  the  centre  of  the 
bladder,  raised  from  the  base,  and  may  be  moved  about  slightly 
in  various  directions  to  facilitate  the  flow  of  the  fragments 
towards  the  eye ;  but  towards  the  completion  of  the  process 
the  cannula  should  be  allowed  to  rest  on  the  base,  so  as  to 
gather  up  the  sand  and  last  fragments. 

Towards  the  completion  of  the  operation  it  will  be  found 
that,  as  a  rule,  the  last  particles  of  debris  lie  close  to  the  neck 
of  the  bladder,  just  behind  the  prostate.  This  is  due  to  the 
fact  that  the  eye  of  the  cannula  being  turned  towards  the 
posterior  aspect  and  sides  of  the  bladder,  the  water  is  less  dis- 
turbed by  currents  in  the  position  referred  to  than  in  any 
other.  Consequently,  the  last  particles  of  debris  gravitate 
towards  this  spot.  Towards  the  end  of  the  operation,  there- 
fore, the  eye  of  the  cannula  should  always  be  turned  right 
round  towards  the  prostate,  and  water  forcibly  injected,  so  as 
to  dislodge  the  debris  from  this  position.     This  manoeuvre  is 


THE  OPERATION  OF  LITHOLAPAXY  45 

especially  necessary  where  enlargement  of  the  prostate  co- 
exists, otherwise  a  fragment  might  be  left  behind. 

On  compressing  the  bulb  and  pumping  water  into  the 
bladder,  the  debris  is  scattered  away  from  the  eye  of  the 
cannula.  Before  allowing  the  stream  to  return  by  the  ex- 
pansion of  the  bulb,  the  hand  should  rest  a  second  or  two,  so 
as  to  allow  the  debris  to  settle  down  again  in  the  vicinity  of 
the  eye.  The  evacuation  of  the  debris  will  sometimes  be  found 
to  take  place  best  by  injecting  three  or  four  ounces  of  water 
into  the  bladder  with  each  compression  of  the  bulb  ;  at  others 
a  much  smaller  quantity  will  be  found  most  effectual.  No 
definite  rule  can  be  laid  down  for  all  cases. 

Sir  Henry  Thompson  lays  stress  on  the  necessity  of  havmg 
the  movements  of  the  aspirator  synchronous  with  those  of  the 
chest  during  resxDiration ;  the  water  being  pumped  into  the 
bladder  durmg  expiration,  and  exhausted  therefrom  during 
inspiration.  During  my  earlier  operations  I  had  recourse  to 
this  manoeuvre  a  good  deal,  but  I  came  long  ago  to  regard  it 
as  an  unnecessary,  and,  indeed,  frequently  impracticable, 
refinement.  Patients  vary  so  much  in  the  rapidity  of  theh 
breathmg  under  the  influence  of  an  anaesthetic  that  the  sug- 
gestion frequently  cannot  be  attended  to,  even  if  desired. 

It  sometimes  happens,  even  when  the  patient  is  fully 
anaesthetized,  that  spasm  of  the  bladder  occurs.  During  its 
existence  all  manipulation  should  be  suspended,  otherwise  the 
bladder  might  be  injured.  This  is  a  point  to  which  Mr, 
Eeginald  Harrison  has  called  attention,*  and  the  precaution 
indicated  is  a  wise  one.  Should  the  lithotrite  be  in  the  bladder, 
it  must  be  closed  and  kept  unmoved  till  the  spasm  passes 
over.  If  the  cannula  be  in  the  bladder  the  water  should  be 
allowed  to  escape. 

Durmg  the  process  of  aspiration,  with  each  expansion  of  the 
indiarubber  bulb  the  fragments  of  calculi  are  carried  agamst 
*  '  Lithotomy,  Litliotrity,'  etc.,  by  E.  Harrison,  1SS3,  p.  35. 


46  THE  OPERATION  OF  LITHOLAPAXY 

the  eye  of  the  cannula  by  the  outward  rush  of  water,  and  a 
dickmg  sound  is  thus  produced,  which,  whilst  it  continues, 
indicates  that  some  fragments  remain  in  the  bladder.  There 
is,  however,  a  peculiar  sound  sometimes  produced,  the  occur- 
rence of  which  the  young  litholapaxist  should  be  acquamted 
with,  as  it  is  very  likely  to  be  confounded  with  the  sound  pro- 
duced by  a  fragment.  This  '  false  sound,'  as  it  may  be  called, 
is  produced  by  the  mucous  membrane  of  the  bladder  being 
sucked  into  the  eye  of  the  cannula  during  exhaustion  of  the 
water.  It  is  most  likely  to  occur  towards  the  end  of  the  opera- 
tion, when  all,  or  nearlj^  all,  the  fragments  have  been  ex- 
hausted, and  especialty  when  the  bladder  contains  no  surplus 
water,  only  that  quantity  which  is  pumped  in  and  withdrawn 
dm'ing  compression  and  expansion  respectively  of  the  bulb. 
It  may,  however,  be  produced  at  any  time  if,  after  compressing 
the  bulb,  the  eye  of  the  cannula  be  turned  towards  the  sides, 
or  directed  up  against  the  apex  of  the  bladder,  and  the  bulb  of 
the  aspirator  be  then  allowed  to  expand.  The  sound  itself, 
though  difficult  to  describe,  can  never  be  mistaken  when  once 
recognized.  The  sensation  communicated  to  the  hand  is  of  a 
fluttering,  jerky  character,  accompanied  by  a  dull,  muffled 
sound,  as  contrasted  with  the  clear,  ringing  click  which  the 
impact  of  fragments  imparts  to  the  instrument.  On  its  occur- 
rence the  outward  stream  receives  a  sudden  and  complete 
check ;  whereas,  when  a  fragment  obstructs  the  stream,  a 
portion  of  the  water  continues  to  flow.  The  sound  does  not 
recur  if  the  cannula  be  partially  withdrawn  and  raised  towards 
the  perpendicular  position,  so  as  to  bring  the  eye  close  to  the 
neck  of  the  bladder,  with  the  end  of  the  cannula  resting  on 
the  trigone ;  whereas  a  fragment  will  produce  obstruction 
there  as  well  as  in  any  other  position.  On  first  practising 
litholapaxy  I  was  deceived  by  this  sound,  and  since  then  I 
have  seen  man}^  young  and  inexperienced  litholapaxists  simi- 
larly deceived. 


THE  OPERATION  OF  LITHOLAPAXY  47 

It  frequently  happens  that,  durmg  the  process  of  aspkation, 
a  fragment  which  is  too  large  to  pass  through  the  cannula  gets 
caught  in  its  eye.  This  is  recognised  by  the  fact  that  the 
outward  stream  is  arrested,  and  the  bulb  of  the  aspirator 
ceases  to  expand.  The  fragment  should  at  once  be  displaced. 
This,  as  a  rule,  may  be  effected  by  compressing  the  bulb 
suddenl}^  and  with  force,  when  the  fragment  will  be  expelled 
by  the  inward  stream.  Should  this  manoeuvre  fail  after  being 
tried  two  or  three  times,  a  stylet  should  be  introduced  through 
the  cannula,  and  the  fragment  displaced  in  this  way.  But 
the  cannula  should  on  no  account  be  withdrawn  with  the 
fragment  sticking  in  its  eye,  as  in  this  way  the  urethra  may 
be  injured,  or  the  fragment  get  caught  in  the  mucous 
membrane,  displaced  from  the  eye  of  the  cannula,  and  thus 
impacted  in  the  urethra. 

Should  a  fragment  get  impacted  in  the  urethra,  how  are  we 
to  deal  with  it  ?  If  the  precautions  indicated  in  the  last 
paragraph  are  taken,  there  will  be  little  fear  of  its  occurrence. 
Still,  it  is  an  accident  that  has  to  be  reckoned  on.  If  the 
fragment  be  lodged  in  the  prostatic  portion  of  the  urethra,  it 
may  easily  be  displaced  backwards  into  the  bladder  by  passing 
a  large  cannula  as  far  as  the  obstruction,  applying  the 
aspirator,  and  injecting  water  with  some  force,  when,  as  a 
rule,  the  fragment  will  rush  back  into  the  bladder,  to  be  there 
disposed  of.  If  the  fragment  be  arrested  in  the  anterior  three 
or  four  inches  of  the  canal,  it  can  be  removed  with  one  or 
other  of  the  various  kinds  of  urethral  forceps  in  use  (Figs. 
29,  30,  31).  When  deeply  placed  in  the  membraneous  portion 
of  the  canal,  it  may  still  be  removed  in  this  manner ;  but,  if 
tightly  impacted,  it  may  be  necessary  to  remove  it  by  external 
urethrotomy. 

Where  there  is  great  irregularity  of  the  inner  surface  of  the 
bladder,  it  may  be  extremely  difficult  to  get  rid  of  the  last 
fragment.     I  have  experienced  this  frequently.     The  aspirator 


48 


THE  OPERATION  OF  LITHOLAPAXY 


is  applied,  and  time  after  time  the  fragment  clicks  against  the 
eye  of  the  cannula,  but,  on  introduction  of  the  lithotrite,  the 
fragment  cannot  be  grasped.  Great  perseverance  may  be 
necessary,  especially  if  the  fragment  be  a  broad,  thin  shell 
from  the  outer  crust  of  a  large  stone.  A  manoeuvre  that 
I  have  found  useful  is  to   employ  the  suction  force  of   the 


'l3   SC/tLE 

Fig.  31. 


cannula  and  aspirator  to  bring  the  fragment  out  of  the 
depression  in  which  it  lies,  close  to  the  neck  of  the  bladder, 
and  then  to  introduce  the  lithotrite  and  catch  the  fragment  in 
this  position.  If  the  fragment  lies  in  a  depression  behind  the 
prostate,  the  forefinger  may  be  mtroduced  into  the  rectum. 
The  lithotrite  bemg  in  the  bladder,  the  fragment  of  stone 
may  now  be  pushed  out  of  the  depression  in  which  it  lies  by 
the  point  of  the  finger,  and  caught  by  the  lithotrite  with  a 


THE  OPERATION  OF  LITHOLAPAXY  49 

little  manipulation.  This  manoeuvre,  which  I  have  frequently 
found  successful,  was  suggested  to  me  by  my  friend  Surgeon- 
Major  J.  Blood,  now  of  Birkenhead. 

The  larger  the  evacuating  cannula,  the  less  necessity  there 
will  be  for  crushing  the  calculus  into  fine  powder,  and,  conse- 
quently, the  less  time  will  the  operation  require  for  its  per- 
formance— a  matter  of  no  small  importance  when  we  have  to 
deal  with  a  large  stone  in  a  patient  whose  constitution  has 
been  very  much  worn  by  the  disease.  It  is,  therefore, 
advisable  to  employ  the  largest  cannula  that  will  pass  with 
ease  into  the  bladder.  I  cannot  too  strongly  deprecate  the 
use  of  any  force  in  passing  a  catheter,  or,  indeed,  any 
instrument,  into  the  bladder ;  but  the  baneful  effects  which 
Sir  Henry  Thompson  anticipated  from  the  use  of  large 
instruments,  experience  has  shown  to  be  imaginary.  Sir 
Henry  says  that  the  instruments  should  be  proportionate  to 
the  size  of  the  stone,  but  experience  has  taught  me  that  the 
capacity  of  the  urethral  canal  is  of  much  more  importance  in 
determining  the  size  of  the  instruments,  and  that  the  largest 
lithotrite  and  cannula  that  can  be  passed  without  the  use  of 
any  force  should  be  employed.  A  large  lithotrite  is  much 
handier  in  the  bladder,  less  liable  to  get  clogged  by  debris, 
and  much  more  efficient,  not  only  for  crushing  large  calculi, 
but  for  disposing  of  fragments  of  debris,  than  a  small  one  ;  and 
I  fully  agree  with  Bigelow  that  when  one  gets  accustomed  to 
the  use  of  a  large  lithotrite  he  does  not  willingly  abandon  it 
for  a  smaller  instrument. 

It  will  be  absolutely  necessary  to  have  recourse  to  large 
instruments  much  more  frequently  in  India  than  in  this 
country,  for  the  simple  reason  that  the  great  majority  of 
calculi  are  large  when  coming  under  observation  in  the 
former  country. 

As  a  rule,  there  ought  to  be  little  or  no  loss  of  blood 
attending  the  operation,  with  the   exception  of  the   trifling 

4 


50  THE  OPERATION  OF  LITHOLAPAXY 

bleeding  that  follows  the  incision  in  the  floor  of  the  urethra, 
when  this  is  necessary  to  enlarge  the  meatus.  I  have  fre- 
quently removed  very  large  calculi  with  scarcely  a  tinge  of 
blood  in  the  washings  from  beginning  to  end.  In  some 
cases,  however,  the  mucous  membrane  of  the  urethra  is 
highly  sensitive  to  the  passage  of  instruments,  and  consider- 
able bleeding  takes  place.  In  such  cases  I  am  in  the  habit  of 
using  a  weak  astringent  in  the  washings — say,  \  grain  of 
acetate  of  lead  to  the  ounce — and  winding  up  the  proceedings 
with  a  stronger  solution. 

The  operation  being  completed,  the  patient  should  be  put 
to  bed,  and  well  wrapped  up  in  warm  clothing.  A  morphia 
suppository  should  be  at  once  introduced.  In  India  I  was  in 
the  habit  of  administering  a  large  dose  of  quinine  as  soon  as 
the  patient  recovered  consciousness,  and  repeating  the  drug 
in  smaller  doses  for  a  few  days.  I  follow  the  same  practice 
in  England  after  all  operations  involving  the  passage  of 
instruments  through  the  urethra  on  patients  who  have  lived 
in  malarial  climates.  Such  persons  are  particularly  prone  to 
fever  after  operations  on  the  urinary  organs,  and  there  is  no 
doubt  that  the  Judicious  administration  of  quinine,  combined 
with  an  opiate,  has  frequently  the  effect  of  warding  off  such 
attacks.  The  food  for  the  first  few  days  should  be  of  a  light 
kind,  consisting  mainly  of  milk  and  soups.  A  demulcent 
and  alkaline  drink  should  be  allowed.  My  favourite  mixture 
is  a  quart  of  barley-water,  mixed  with  which  are  one  drachm 
each  of  liquor  potassse  and  tinct.  hyoscyami,  and  this  the 
patient  is  encouraged  to  drink  freely. 

For  the  first  twenty  or  thirty  hours  the  urine  may  be  tinged 
with  blood,  particularly  till  the  operator  has  had  large 
experience  in  this  branch  of  surgery,  and  there  will,  as  a  rule, 
be  considerable  burning  sensation  along  the  course  of  the 
urethra,  with  some  difficulty  of  micturition.  The  treatment 
indicated  in  the  last  paragraph  will  tend  to  alleviate  these 


THE  OPERATION  OF  LITHOLAPAXY  51 

symptoms.  Should  there  be  any  pain  or  tenderness  on 
pressure  in  the  region  of  the  bladder,  hot  fomentations, 
assiduously  applied,  followed  by  hot  poultices  to  the  hypo- 
gastric region,  will  be  found  soothing;  and  pain  in  the 
perineal  region  will  be  lessened  by  painting  with  extract  of 
belladonna,  after  fomenting  the  parts. 

Eetention  of  urine  is  a  rare  sequel  of  the  operation,  for 
which  a  hot  hip-bath  will  be  found  most  effectual.  Should 
this  fail,  recourse  must  be  had  to  the  catheter.  More  rare 
still  is  total  suppression  of  urine,  which  should  be  dealt  with 
on  general  medical  principles.  This  occurs  only  in  patients 
whose  kidneys  are  diseased,  and  is  of  very  grave  import. 

When  the  patient  is  the  subject  of  atony  of  the  bladder  or 
enlargement  of  the  prostate,  it  may  be  advisable  to  pass  and 
tie  in  a  soft  catheter  for  a  few  days,  to  allow  the  water  to  flow 
in  this  way. 

Acute  inflammation  of  the  testicle  is  a  sequel  of  the 
operation  that  has  from  time  to  time  occurred  in  my  practice, 
and  readily  yielded  to  the  ordinary  treatment  for  that  com- 
plication. 

The  most  frequent  sequel  of  the  operation  in  India  is  the 
occurrence  of  fever.  To  the  ordinary  catheter  or  urethral 
fever,  long  recognized  as  attending  the  passage  of  instruments 
through  the  urethra,  we  have  superadded,  as  it  were,  the 
effects  of  malaria ;  and  the  supervention  of  this  fever  is  a 
contingency  that  will  have  to  be  reckoned  with  in  a  large 
proportion  of  the  cases  dealt  with.  The  attack  sets  in,  as  a 
rule,  a  few  hours  after  the  operation,  frequently  after  the  first 
act  of  micturition,  and  passes  through  the  usual  stages — cold, 
hot,  and  sweating — of  an  ordinary  attack  of  intermittent  fever, 
from  which  it  is  scarcely  to  be  distinguished.  The  treatment 
will  also  be  the  same  as  in  ague — extra  warm  clothing,  hot- 
water  bottles  to  the  extremities,  and  the  administration  of  hot 
drinks,  particularly  tea,  during  the  cold  stage.    As  this  passes 


52  THE  OPERATION  OF  LITHOLAPAXY 

into  the  hot  stage,  part  of  the  clothing  must  be  removed,  and 
the  patient's  thirst  relieved  by  copious  drinks  of  water, 
lemonade,  etc.  The  ordinary  fever  mixture  should  also  be 
given  to  encourage  perspiration.  When  the  sweating  stage 
sets  in,  warm  clothing  must  be  again  supplied  to  encourage 
perspiration,  and  prevent  the  patient  catching  cold.  During 
the  intermission  quinine  should  be  given.  The  fever  is,  as  a 
rule,  very  amenable  to  treatment. 

The  operation  is  undoubtedly  a  difficult  one,  perhaps  the 
most  difficult  in  the  whole  range  of  operative  surgery,  and 
should  not  be  lightly  undertaken  by  inexperienced  hands. 
There  are  some  men  whose  hands  were  never  made  for 
the  use  of  surgical  instruments,  and  my  advice  to  such  is 
not  to  undertake  this  operation.  There  are  other  spheres  in 
the  medical  profession  of  as  much  usefulness  as  this  particular 
branch  of  operative  surgery.  In  1867  Sir  William  Fergusson, 
writing  of  lithotrity,  said  :  '  I  know  not  any  process  in  surgery 
requiring  more  forethought,  knowledge,  manipulative  skill, 
and  after-judgment.'  And  if  this  remark  of  one  of  the  most 
distinguished  lithotritists  of  his  day  was  true  of  the  old 
operation  of  lithotrity,  how  much  more  is  it  applicable  to  the 
modern  operation  of  litholapaxy,  in  which  instruments  of 
much  larger  size  and  greater  power  than  formerly  used  are 
employed,  in  which  calculi  of  much  larger  dimensions  are 
attacked,  and  in  which  the  proceedings  are  extended  over 
much  longer  periods.  Patience,  perseverance,  gentleness, 
dexterity,  a  light  touch,  and,  above  all,  experience,  are 
essential  to  make  a  man  a  good  litholapaxist.  I  do  not 
hesitate  to  say  that  on  every  occasion  that  I  have  performed 
the  operation  I  have  learnt  something  new.  In  this  fact 
consists  one  of  the  great  beauties  of  the  operation,  so  far  as 
the  surgeon  is  concerned.  It  is  always  a  ifield  of  novel 
research. 

It   has  been  said   that   no   novice   should   undertake   this 


THE  OPERA  TION  OF  LITHOLAPAXY  53 

operation ;  and  this  is  undoubtedly  true  so  far  as  the  great 
body  of  the  profession  at  home  is  concerned,  the  majority  of 
whom  pass  months,  sometimes  years,  without  undertaking  an 
operation  of  any  magnitude,  and  where  the  opportunities  for 
operating  for  stone  are  so  few.  But  the  case  is  different  in 
India.  There  are  few  officers  of  the  Indian  Medical  Service, 
holding  civil  appointments,  who  do  not  reckon  their  major 
operations  annually  by  the  hundred,  and  in  many  instances 
by  the  thousand.  During  the  past  few  years  a  healthy  spirit 
of  rivalry,  as  to  the  amount  of  good  work  done,  has  entered 
the  ranks  of  the  Service  ;  and  I  do  not  hesitate  to  say  that 
there  are  now  many  hospitals  in  India,  where  more  operations 
are  undertaken  single-handed  by  the  Civil  Surgeon  than  by  the 
whole  staff  in  some  of  the  largest  London  hospitals.  It  goes 
without  saying  that  the  large  experience  thus  acquired  must 
give  to  the  surgeon  practising  in  India  a  manipulative  dexterity 
in  the  use  of  surgical  instruments,  an  amount  of  self-reliance, 
boldness,  and  judgment  in  dealing  with  difficulties  that 
unexpectedly  arise,  which  can  be  rarely  acquired  elsewhere. 
This  being  the  case,  why  should  he  hesitate  to  undertake 
litholapaxy,  with  such  frequent  opportunities  of  putting  the 
operation  into  practice  ? 

The  beginner  will  do  well  to  commence  by  operating  on 
cases  where  the  stone  is  small  and  the  urethra  capacious.  As 
experience  is  acquired  large  calculi  and  those  attended  by 
complications  are  to  be  attacked. 

Previous  to  undertaking  the  operation  for  the  first  time,  it 
will  be  well,  when  possible,  for  the  surgeon  to  pay  a  visit  to 
one  of  those  hospitals  where  the  operation  is  performed.  More 
information  will  be  gained  by  seeing  the  operation  once  well 
performed  than  from  any  amount  of  reading  and  theoretical 
knowledge.  It  is  not  the  object  of  this  work  to  take  the  place 
of  practical  knowledge,  but  rather  to  assist  and  supplement  it. 


CHAPTER  IV. 

THE    AUTHOR'S    EXPERIENCE     OF   LITHOLAPAXY, 
WITH  COGNATE  STATISTICS. 

In  the  preceding  pages  I  have  endeavoured  to  give  a  clear  and 
concise  description  of  the  operation  of  litholapaxy,  and  the 
instruments  employed  in  its  performance.  Before  proceeding 
to  deal  with  the  special  difficulties  and  complications  met  with 
in  this  operation,  and  the  peculiarities  of  its  application  to 
male  children  and  females  of  all  ages,  it  will  be  convenient, 
and  tend  to  avoid  repetition,  if  I  now  give  the  results  of  my 
own  experience  of  the  operation,  with  some  cognate  statistics. 
My  first  lithotomy  operation  was  performed  on  May  4,  1877, 
and  since  that  time  I  have  operated  on  864  cases  of  stone  in 
the  bladder  by  all  methods,  viz. : 


Perineal  lithotomy 

Suprapubic  lithotomy 

Vaginal  hthotomy 

Rapid  dilatation  of  urethra  in  females 

Litholapaxy    ... 


244 
6 
1 
3 

610 

Total    864 


Though  for  statistical  purposes  it  will  be  necessary  for  me 
to  deal  comprehensively  with  the  whole  of  my  operations  for 
stone  in  the  bladder,  it  is  to  these  latter  610  cases  dealt  with 
by  Bigelow's  method  that  I  propose  directmg  particular  atten- 
tion in  this  work,  demonstrating  thereby  what  a  vast 
influence  the  modern  operation  has  had  in  ameliorating  the 


THE  AUTHOR'S  EXPERIENCE  OF  LITHOLAPAXY       55 

sufferings  and  diminishing  the  mortality  attendant  on  this 
painful  disease. 

Since  performing  my  first  litholapaxy  operation,  July  3, 
1882,  I  have  from  time  to  time  published  papers  in  the 
medical  journals*  giving  full  details  of  several  series  of  this 
operation  performed  by  me.  The  great  majority  of  these 
operations  were  done  in  hospital  practice ;  and  careful  notes 
of  every  case  have  been  kept  by  my  assistant  surgeons  and 
myself.  In  a  large  proportion  I  have  had  the  pleasure  of 
operating  in  presence  of  one  or  more  surgeons,  and  showing 
them  the  results.  There  was  no  selection  of  cases,  my  rule 
being  to  operate  on  every  patient  suffering  from  stone  coming 
under  my  care,  no  matter  in  what  condition.  No  case  was 
allowed  to  leave  hospital,  or  observation  in  case  of  private 
practice,  till  a  cure  had  been  effected.  This  monograph  may 
therefore  be  accepted  as  an  accurate  and  trustworthy  record  of 
work  in  this  branch  of  surgery.  It  is  hoped  that  such  a  record 
of  a  large  number  of  cases  of  this  operation  from  the  practice 
of  a  single  operator  may  prove  interesting  to  the  profession. 

There  were  amongst  these  610  cases  of  litholapaxy  439 
adults — viz.,  432  males  and  7  females  ;  and  171  children — 
viz.,  165  males  and  6  females. 

The  adults  varied  m  age  from  16  to  96  years,  the  average 
being  482- ;  the  children  from  1^  to  under  16  years,  the 
average  being  just  7. 

The  average  number  of  days  spent  in  hospital  after  the 
operation,  or  under  treatment  in  case  of  private  patients,  was, 
in  the  case  of  adults,  6|-  days,  the  period  varying  from  2  to 
28  days ;  in  the  case  of  children  5f  days,  varying  from  2  to 
31  days.     I  may  mention,  however,  that  in  many  instances 

*  Indian  Medical  Gazette,  Dec.  1882,  Feb.  1883,  March  1884,  AprU 
1885,  Jan.  1886,  Feb.  1886 ;  the  Lancet,  Feb.  28,  March  7  and  14,  1885 ; 
British  Medical  Journal,  Dec.  24,  1887  ;  Oct.  12,  1889  ;  May  9,  1891 ; 
July  16,  1894. 


56        THE  AUTHORS  EXPERIENCE  OF  LITHOLAPAXY 

the  patients  were  kept  in  hospital  one,  two,  or  three  days 
longer  than  absolutely  necessary,  as  a  precautionary  measure 
or  for  purposes  of  observation. 

The  debris  of  calculi  removed  varied  in  weight  in  adults 
from  2  grains  to  6|-  ounces,  the  average  weight  being  262 
grains ;  in  children  from  1^  grains  to  3  ounces  and  2^  drachms, 
the  average  being  95^  grains.  The  weights  here  given  are 
those  of  the  debris  when  dried ;  and  the  specimens  have  all 
been  jpreserved  by  me.  There  were  192  calculi  weighing  half 
an  ounce  and  upwards ;  90  one  ounce  and  more ;  31  two 
ounces  and  over  ;  8  three  ounces  and  upwards,  and  1  weighing 
6^  ounces. 

These  610  operations  occurred  in  599  different  individuals, 
the  disease  having  recurred  once  in  nine  instances,  and  twice 
in  one  instance.  In  three  other  cases  litholapaxy  had  been 
previously  performed  by  other  surgeons.  In  all  these  cases 
long  intervals  had  elapsed  between  the  first  operation  and  the 
recurrence  of  the  symptoms  of  stone ;  and,  after  careful 
inquiry,  I  am  bound  to  say  that  neither  in  the  cases  of  those 
previously  operated  on  by  myself  nor  in  those  operated  on  by 
others  did  the  recurrence  seem  to  be  due  to  a  fragment  having 
been  left  behind  at  the  first  operation.  They  were  all  simple 
cases  of  recurrence  of  stone  from  constitutional  causes.  In 
eight  other  instances  the  patients  had  previously  undergone 
lithotomy,  three  of  them  twice.  Three  of  these  lithotomy 
operations  had  been  performed  by  myself.  I  attribute  the 
rarity  of  recurrence  of  stone  after  litholapaxy  in  my  practice 
to  the  extreme  care  exercised  by  me  in  seeing  that  the  last 
fragments  of  calculus  are  removed.  So  far  as  my  own 
experience  goes,  recurrence  of  stone  is  as  frequent  after 
lithotomy  as  after  litholapaxy.  Dr.  Keegan  informs  me  that 
this  is  also  his  experience  of  the  two  operations.  I  find, 
however,  that  Sir  Henry  Thompson's  850  cases — 478  by 
lithotrity,  and  372  by  litholapaxy,  or  '  lithotrity  at  one  sitting,' 


THE  AUTHORS  EXPERIENCE  OF  LITHOLAPAXY       57 

as  he  calls  it — occurred  in  730  individuals,*  there  being  thus 
no  fewer  than  120  '  recurrent '  operations  for  stone,  or  over 
16  per  cent.     I  shall  have  to  refer  to  this  later  on. 

The  length  of  time  occupied  by  the  operation  ranged  from 
a  couple  of  minutes  to  Sj  hours.  It  vill  vary,  of  course,  ^vith 
the  size  and  consistence  of  the  stone,  the  capacity  of  the 
urethra,  the  facility  with  which  the  instruments  can  be 
introduced,  and  the  experience  and  dexterity  of  the  operator. 
I  am  now  in  the  habit  of  crushing  as  much  of  the  stone  as 
possible  before  withdrawing  the  lithotrite,  so  that  in  most 
cases  of  stone  of  ordinary  size  only  one  introduction  of  this 
instrument  is  necessary.  The  repeated  mtroductions  of 
instruments  should,  I  think,  be  avoided  as  much  as  possible. 
Eapidity  of  execution  is  a  quality  which  comes  with  practice  ; 
and  there  is  no  doubt  that,  all  undue  haste  and  roughness  of 
manipulation  being  avoided,  it  is  desirable  to  complete  the 
operation  as  rapidly  as  possible,  particularly  when  the  patient 
is  old  and  much  enfeebled  by  the  disease. 

The  patients  were,  as  a  rule,  angesthetized  during  the 
operation.  During  the  last  three  or  four  years  I  have,  how- 
ever, been  performing  the  operation  without  an  ansesthetic  in 
an  increasing  number  of  suitable  cases.  With  a  capacious 
urethra  m  an  adult  I  should  not  hesitate  to  attack  a  stone  of 
about  an  ounce  in  weight  without  the  aid  of  an  anesthetic, 
or  with  local  ansesthesia  by  cocaine  only,  in  a  case  in  which 
the  internal  administration  of  an  ansesthetic  was  undesirable, 
or  strongly  objected  to  by  the  patient. 

Amongst  these  610  litholapaxy  operations  there  were  many 
cases  in  which  the  calculous  disorder  was  complicated  by  the 
co-existence  of  urethral  stricture.  Hypertrophy  of  the  prostate 
was  also  present  in  a  large  proportion  of  cases.  The  methods 
of  dealing  with  these  troublesome  complications  will  be  fully 
dealt  with  later  on. 

*  Introduction  to  'Catalogue  of  Calculi,  etc.,'  Chuxcliill,  1893. 


S8        THE  AUTHORS  EXPERIENCE  OF  LITHOLAPAXY 

Cystitis  accompanied  the  calculous  disorder  in  a  large 
proportion  of  cases,  and  in  many  instances  the  urine  was 
fetid.  For  this  complication  no  special  treatment  is,  as  a 
rule,  necessary,  the  removal  of  the  stone,  the  cause  of  the 
cystitis,  almost  invariably  resulting  in  its  disappearance. 

Many  of  the  patients  also  suffered  from  enlargement  of  the 
spleen,  dysentery,  piles,  prolapsus  ani,  and  other  diseases. 
In  short,  no  ease  of  stone  commg  mider  my  care  has  been 
refused  the  benefit  of  operation,  no  matter  in  what  state  of 
health,  some  having  been  apparently  moribund  when  placed 
on  the  operating  table. 

Under  these  circumstances  I  need  scarcely  add  that  kidney 
disease  in  all  its  stages  was  frequently  present ;  but  so  far  as 
the  performance  of  litholapasy  goes  I  never  desist  from  the 
operation  on  this  account ;  for  no  matter  what  the  state  of 
the  kidneys  may  be  I  perform  the  operation,  knowing  that 
it  gives  the  best  prospect  of  recovery.  Contrast,  in  this 
respect,  Bigelow's  operation  with  the  old  operation  of  litho- 
trity,  which  was  contra-indicated  when  kidney  disease  was 
present ! 

Amongst  these  610  litholapaxy  cases  there  were  11  deaths, 
\dz.,  9  amongst  439  operations  on  adults,  and  2  amongst  171 
on  children.  These  fatal  cases,  with  the  exception  of  the  last 
two,  have  been  fully  reported  in  the  medical  journals  already 
referred  to ;  and  the  details  of  the  remaining  two  will  be 
given  in  due  course.  The  causes  of  death  were  :  exhaustion, 
5  (with  pneumonia  superadded  m  1)  ;  peritonitis,  2  ;  pyaemia, 
1 ;  acute  nephritis,  1 ;  and  acute  cystitis,  2.  All  these  cases 
were  in  bad  health  when  coming  under  operation  except  one  ; 
and  this  patient  had  had  retention  of  urme  for  thirty-six 
hours,  with  the  calculus  blocking  the  prostatic  urethra.  The 
kidneys  were  diseased  m  several  of  these  cases,  particularly  in 
one,  from  whom  I  removed  3;^  ounces  of  oxalate  of  lime-stone, 
and  in  the  case  which  died  from  acute  nephritis.     In  this 


THE  AUTHORS  EXPERIENCE  OF  LITHOLAPAXY       59 

latter  I  found  at  the  autopsy  two  calculi  in  the  right  kidney, 
weighing  2  drachms.  One  patient  was  ninety  years  of  age. 
One,  a  child  of  thirteen  years,  who  died  of  cystitis,  had  been 
roughly  sounded  a  week  before  coming  under  my  care,  since 
which  time  he  had  been  in  great  agony,  so  that  probably  the 
bladder  had  been  injured  durmg  the  sounding. 

The  11  deaths  m  610  litholapaxy  operations — viz. ,439  adults 
with  9  deaths,  and  171  children  with  2  deaths  —  give  a 
mortality  of  1*80  per  cent,  on  the  whole,  or  about  2  per  cent. 
in  adults  and  1-17  per  cent,  in  children.  There  were,  on  the 
other  hand,  254  lithotomies  in  my  practice  with  11  deaths — 
viz.,  54  adults  with  10  deaths,  and  200  children  with  1  death 
— giving  a  mortality  of  4-^  per  cent,  on  the  whole,  or  18|  per 
cent,  in  adults,  with  \  per  cent,  in  children. 

This  is,  however,  not  a  fair  method  of  comparing  the 
results  of  the  two  operations,  as,  since  the  introduction  of 
litholapaxy  into  my  practice,  only  those  patients  that  were 
unsuitable  for  this  operation  were  subjected  to  lithotomy. 
Previous  to  my  commencing  to  operate  by  litholapaxy  I  had 
done  94  lithotomies,  of  which  33  were  in  the  adult  with  6 
deaths,  or  a  mortality  of  18  per  cent.,  there  being  no  deaths 
amongst  children.  Since  then  I  have  performed  770  operations 
in  all  with  16  deaths,  or  about  2  per  cent. — viz.,  460  in  the 
adult  (439  litholapaxies  with  9  deaths,  and  21  lithotomies 
with  4  deaths)  with  13  deaths,  or  less  than  3  per  cent. ;  and 
310  in  children  (171  litholapaxies  with  2  deaths,  and  139 
lithotomies  with  1  death)  with  3  deaths,  or  about  1  per  cent. 
This  is  the  proper  method  of  comparing  the  results  of  the  two 
operations  ;  and,  setting  aside  the  results  in  children,  in  whom 
Lithotomy  has  always  been  a  comparatively  successful  operation, 
it  will  be  observed  that  the  introduction  of  litholapaxy  into  my 
practice  has  had  the  effect  of  reducing  the  mortality  in 
operations  for  stone  in  the  adult  from  18  to  3  per  cent. 

I  may   point   out    that    though    I    have    been   singularly 


6o        THE  A  UTHOR'S  EXPERIENCE  OF  LITHOLAPAXY 

fortunate  in  my  litJiotomy  cases  in  children,  the  mortaUty 
attendmg  this  operation  m  the  adult  in  my  hands  approxi- 
mates pretty  closely  to  that  recorded  in  hospital  practice  both 
in  England  and  India.  Thus,  Sir  Henry  Thompson  has 
collected  details  of  1,827  lithotomies  performed  in  British 
hospitals  previous  to  the  introduction  of  litholapaxy,  showmg 
229  deaths,  or  12-1  per  cent.  There  were  1,028  children  with 
68  deaths,  or  6|  per  cent.,  and  799  adults  with  161  deaths,  or 
20  per  cent.  In  an  article  in  the  Lancet,  March,  1885, 1  gave 
the  statistics  of  2,592  lithotomy  operations  performed  in 
Indian  hospitals  in  1882,  showing  a  mortality  of  about  13  per 
cent,  on  the  whole — practically  the  same  as  in  British  hospitals. 
When  I  commenced  to  perform  litholapaxy  in  1882,  I  at 
first  adopted  this  operation  in  selected  cases  in  the  adult  only, 
relegatmg  the  difficult  cases  to  lithotomy ;  then,  as  I  gained 
experience,  extending  it  to  most  of  my  adult  cases.  Then  in 
1886,  influenced  by  Keegan's  results,  I  extended  the  operation 
to  male  children.  I  have  now  practically  abandoned  lithotomy 
in  my  practice  in  favour  of  litholapaxy,  the  force  of  which 
remark  will  be  seen  when  I  state  that  amongst  the  last  300 
cases  of  stone  operated  on  by  me  in  patients  of  all  ages  from 
2  to  90  years,  the  calculi  weighing  from  2  grains  to  6|-  ounces, 
there  were  only  6  lithotomies  (1  supra-pubic,  4  perineal  and  1 
vaginal),  the  modern  operation  having  been  found  feasible  in 
all  the  other  29-1  cases.  In  1890  I  had  106  cases  of  stone 
under  my  care,  and  they  w^ere  one  and  all  treated  by  litho- 
lapaxy, with  one  death.  With  results  such  as  these  I  have 
not  felt  inclined  to  follow  the  lead  of  Sir  Henry  Thompson  in 
his  attempt  to  revive  the  operation  of  supra-pubic  lithotomy  m 
cases  of  large  calculi  when  I  could  deal  with  them  by  litho- 
lapaxy, nor  of  his  somewhat  rash  imitators  who  adopt  the 
supra-pubic  operation  in  case  of  small  stones.  I  do  not  think 
that  we  can  expect  to  improve  on  the  results  above  indicated 


THE  AUTHOR'S  EXPERIENCE  OF  LITHOLAPAXY       6i 

whilst  we  continue  to  extend  the  operation  of  litholapaxy  to 
all  patients  coming  under  our  care,  no  matter  in  what  con- 
dition, even  to  apparently  hopeless  cases.  They  are,  indeed, 
results  unequalled,  I  venture  to  say,  in  any  other  large  and 
important  operation  in  surgery,  and  entirely  due  to  the 
introduction  of  Bigelow's  method  of  operating. 


CHAPTER  V. 

DIFFICULTIES     AND    COMPLICATIONS:    ILLUSTRA- 
TIVE CASES. 

Large  Calculi.  —  With  a  capacious  urethra  in  an  adult 
male,  there  being  no  enlargement  of  the  prostate,  and  the 
bladder  being  roomy  and  non-sacculated,  the  experienced 
litholapaxist  should  have  no  difficulty  in  disposing  of  a  stone 
of  moderate  dimensions — say,  under  2  ounces  in  weight. 
When-,  however,  the  stone,  if  at  all  a  hard  one,  exceeds  this 
weight,  the  operation  becomes  a  much  more  serious  and 
difficult  one.  I  find  that  amongst  my  series  of  610  lithola- 
paxy  cases  there  were  31  weighing  2  ounces  and  upward, 
eight  3  ounces  or  over,  and  one  6^  ounces.  The  following 
table  shows  at  a  glance  the  particulars  of  these  operations, 
which  were  all  undertaken  on  male  patients  : 


Serial 
JVo. 

Bate  of 
Operation. 

Age. 

TFeight  of 
Calculus. 

Variety. 

Result. 

oz. 

drs. 

grs. 

16 

Dec.  6,  1882 

60 

3 

2 

0 

Uric 

Successful. 

42 

May  15,  1883 

18 

2 

4 

0 

Garb,  lime 

,, 

44 

May  25,     ,, 

45 

2 

6 

0 

Uric 

Died. 

70 

Nov.  21,    ,, 

80 

2 

0 

55 

,, 

Successful. 

91 

June  21,  1884 

35 

2 

0 

0 

Phosphates 

,, 

97 

Aug.  13,     ,, 

26 

3 

1 

30 

Oxalates  of  lime 

Died. 

111 

Oct.  26,      ,, 

55 

2 

0 

45 

Uric,  oxalate 

Successful. 

123 

Aug.  30,  1885 

60 

3 

2 

30 

Uric 

,, 

126 

Sept.  9,       ,, 

55 

2 

2 

0 

)j 

,, 

136 

Aug.  23,  1886 

50 

2 

0 

0 

Garb,  lime 

, , 

189 

May  27,  1887 

24 

2 

1 

0 

Urates 

199 

July  6,       ,, 

30 

2 

4 

0 

Uric 

>  J 

251 

May  5,  1888 

44 

2 

1 

50 

,, 

DIFFICULTIES  AND  COMPLICATIONS 


63 


Serial 
No. 

Bate  of 
Operation. 

Age. 

Weight  of 
Calculus. 

Variety. 

ResiM. 

oz.    drs.  grs. 

303 

March  25,  1889 

55 

2       6        0 

Uric 

Successful. 

318 

June  3,          ,, 

90 

2       0      39 

,, 

Died. 

350 

Dec.  26, 

15 

3       2      17 

Urates,  Phosph. 

Successful. 

371 

March  4,  1890 

55 

2       6      10 

Uric 

374 

March  21,    ,, 

80 

2       4      37 

Urates 

379 

April  15,     ,, 

75 

3       10 

Uric 

414 

July  30,       ,, 

35 

2       4      19 

,, 

421 

Sept.  6, 

80 

2       4      18 

;; 

433 

Oct.  20,       ,, 

70 

2       0      39 

,, 

458 

Jan.  2,  1891 

20 

3       0        0 

Phosphates 

476 

March  19,  1891 

20 

2       0        4 

Urates 

507 

Jan.  7,  1892 

75 

2       0        1 

J, 

517 

Feb.  20,  ,, 

45 

6       10 

Phosph.  of  lime, 
uric 

523 

March  19,  1892 

50 

2       0        2 

Phosphates 

552 

Sept.  24,      ,, 

58 

3       0      10 

Uric 

580 

Feb.  13,  1893 

65 

2       0      50 

,, 

587 

Feb.  28,     ,, 

60 

2       2      40 

Oxalate  of  lime 

607 

March  3,  1895 

57 

2       0      53 

Phosphates 

The  removal  of  large  calculi  of  these  sizes  demands  much 
patience,  perseverance,  skilful  manipulation,  and  manual 
labour.  It  is,  indeed,  no  light  or  easy  task,  and  will  be  found 
to  call  forth  all  the  resources  of  the  surgeon.  Before  attack- 
ing a  stone  of  2  ounces  and  upwards  by  the  modern  operation, 
a  surgeon  should  have  had  a  considerable  experience  in  deal- 
ing with  smaller  calculi.  The  chief  difficulties  met  with  and 
the  means  by  which  they  may  be  overcome,  are  well  illustrated 
in  the  following  cases,  as  also  in  Case  379,  recorded  in  con- 
nection with  the  complication  of  enlarged  prostate  : 

Case  16. — I.  B.,  aged  60,  admitted  into  the  Moradabad  Civil  Hospital, 
December  3,  1882,  with  all  the  symptoms  of  stone  in  the  bladder,  which 
had  existed  eleven  years.  The  patient  could  only  pass  urine  in  di-ops 
continuously  throughout  the  day  and  night,  and  its  passage  was  attended 
with  great  pain.  His  penis  and  foreskin  were  hypertrophied  from  the 
patient's  constantly  rubbing  the  organ  to  relieve  the  pain  and  irritation. 
A  urethral  calculus  was  felt  in  the  fossa  navicularis.  When  the  patient 
tried  to  pass  urme  he  had  to  rub  and  pull  the  penis,  and  in  this  way  push 
the  urine  past  the  calculus  in  the  urethra.  The  urine  was  mixed  with 
pus  and  blood.     The  faeces  passed  were  ribbon-shaped,  due  to  pressure  of 


64  DIFFICULTIES  AND  COMPLICATIONS 

the  stone  on  the  rectum.  On  passmg  the  finger  into  the  rectum,  a  large 
stone  could  be  felt  in  the  bladder.  The  patient's  health  was  very  bad. 
He  was  pale,  thin,  weak,  and  anaemic,  and  he  had  a  pinched,  anxious 
expression,  the  result  of  long  suffering.  On  December  6  I  performed 
litholapaxy,  the  urethral  calculus  having  first  been  removed  after  slitting 
the  floor  of  the  meatus.  The  operation  lasted  sixty-six  minutes,  and  the 
debris  weighed  3J  ounces,  the  calculus  being  a  hard  uric-acid  one.  Con- 
siderable trouble  was  at  first  experienced  in  grasping  the  stone,  owing  to 
the  contraction  of  the  walls  of  the  bladder  on  it.  This  was  obviated  by 
injecting  water  into  the  bladder.  The  htho trite  was  introduced  at  least  a 
dozen  times,  and  after  each  crushing  a  large  quantity  of  debris  was 
washed  out  through  a  No.  18  cannula.  With  the  exception  of  slight  pain 
in  micturition  during  the  first  day  or  two,  the  patient  had  no  after-trouble. 
He  made  a  rapid  recovery,  and  on  December  15,  when  discharged  from 
the  hospital,  the  following  entry  in  my  note-book  describes  his  condition  : 
'  Patient  now  rid  of  all  bladder  symptoms.  Urine  quite  clear ;  bladder 
retains  a  large  quantity  at  a  time.  Has  grown  fat  and  strong.  Says  he 
has  not  been  so  well  for  several  years.  This  man  was  a  miserable 
creatmre  on  admission  to  hospital  ten  days  ago,  and  now  leaves  it  in 
excellent  health.' 

Case  123. — A  male,  aged  60,  admitted  into  the  Mussoorie  Hospital, 
August  29,  1885,  with  symptoms  of  stone.  The  patient  stated  that  the 
symptoms  had  existed  thu-ty  years,  but  that  they  were  extremely  aggra- 
vated during  the  last  three  years.  He  was  very  weak  and  emaciated,  and 
scarcely  able  to  stand  up.  He  agreed  to  an  operation,  provided  that  it 
should  not  be  a  cutting  one.  On  August  30  I  performed  Htholapaxy, 
Surgeon-Major  W.  Murphy  and  Surgeons  A.  Kavenagh  and  C.  R.  Tyrrell 
being  present.  Chloroform  was  given  by  Dr.  Tyrrell.  A  large  somid, 
No.  14,  was  first  passed  with  ease,  after  shtting  the  floor  of  the  meatus 
shghtly.  I  then  attempted  to  pass  the  largest  hthotrite,  but  its  beak  was 
arrested  by  a  pouched  condition  of  the  urethra  near  the  neck  of  the 
bladder.  The  medium-sized  and  smaller  lithotrites  were  then  tried,  but 
with  a  similar  result.  Time  after  time  the  large  steel  sounds  were  passed 
easily,  but  any  sized  lithotrite  I  failed  to  introduce.  Eventually,  after  no 
less  than  twenty-five  rainutes  had  been  wasted  in  the  attempts  to  pass 
the  lithotrites,  a  medium-sized  one  was  passed  successfully.  This  was 
accomplished  by  passing  the  instrument  as  far  as  the  part  at  which  the 
hitch  took  place,  then  depressing  the  handle  between  the  thighs  and  push- 
ing the  instrument  on  with  a  rotatory  motion  in  the  direction  of  the  axis 
of  the  body.  The  medium-sized  lithotrite  could  not  close  on  the  stone, 
so  it  was  withdrawn,  and  the  large  lithotrite  then  easily  passed.  But  the 
stone  could  not  be  grasped,  owing  to  the  walls  of  the  bladder  contracting 
on  it.     It  was  therefore  withdrawn,  and  4  or  5  ounces  of  water  introduced 


DIFFICULTIES  AND  COMPLICATIONS  65 

by  means  of  the  aspirator  and  cannula.  The  stone  was  then  caught  by 
the  large  hthotrite,  which  failed  to  lock,  owing  to  the  large  size  of  the 
stone.  The  long  diameter  of  the  stone  was  then  changed  for  a  shorter 
one,  when  it  was  found  that  the  Hthotrite  locked  -^ith  ease.  The  calculus 
was  extremely  hard  and  tough,  and  required  all  the  force  I  was  capable  of 
to  crush  both  it  and  the  fragments.  The  hthotrite  had  to  be  introduced 
several  times,  and  the  evacuating  catheter,  No.  18,  as  often,  before  the 
whole  of  the  stone  was  removed.  The  fragments  weighed  3  ounces  2^ 
drachms.  The  operation  lasted  one  hour  in  all,  of  which  twenty-five 
minutes  were  wasted  in  unsuccessful  attempts  to  introduce  the  Hthotrites 
at  first.  Once  the  stone  was  grasped,  the  large  hthotrite  soon  disposed  of 
it.  There  was  considerable  bleeding  from  the  urethra  dm-ing  the  early 
manipulations,  though  great  care  was  taken  to  use  no  force.  After  the 
operation  the  patient  was  extremely  weak  and  almost  pulseless.  On 
consciousness  returning,  stimulants  were  given,  and  the  usual  after-treat- 
ment had  recourse  to.  The  stone  was  partly  uric  acid  and  partly  oxalate 
of  lime.  August  31  :  Patient  passed  a  good  night ;  says  that  he  has  not 
had  such  a  good  night's  rest  for  thhty  years  I  Urine  passed  freely,  with 
some  pain,  and  blood-stained.  On  September  1  there  was  some  pain  and 
tenderness  in  the  region  of  the  bladder,  which,  however,  jielded  to  hot 
fomentations.  The  patient's  temperature  never  went  above  100^  F.  He 
suffered  for  a  few  days  from  a  discharge  of  pus,  which  came  fi-om  the 
prostatic  portion  of  the  urethra.  The  patient  put  on  flesh,  and  was  dis- 
charged cm-ed  on  September  24,  though  for  several  days  previously  he  was 
walking  about  the  hospital  inclosure. 

Case  oil.  —  The  patient  was  a  male,  aged  4.5,  with  symptoms  of 
stone  lasting  twelve  years.  He  was  in  wretched  health,  the  ui'ine  being 
muco-purulent  and  fetid.  The  operation  was  performed  on  February  20, 
1892,  Sm-geon-Major  Tuohy  being  present.  "When  placing  the  patient  on 
the  operating-table,  I  imagined  that  supra-pubic  Hthotomy  would  be 
necessary,  but  determined  to  try  Ktholapaxy.  Introducing  my  largest 
hthotrite,  after  some  manipulation  I  caught  a  portion  of  the  stone  (which 
I  found  was  irregular  in  shape),  broke  it  off,  and  reduced  it  to  fine 
fragments.  This  process  I  repeated  again  and  again,  chipping  off  portions, 
or  scraping  the  sides  of  the  stone,  till  I  had  removed  about  three  ounces 
of  debris.  I  then  found  that  the  main  body  of  the  stone  was  lying  in  a 
wide-mouthed  pouch  at  the  posterior  part  of  the  bladder.  After  some 
difficulty  I  grasped  the  stone  in  this  position,  but  could  not  move  it  from 
the  sac  into  the  main  cavity  of  the  bladder.  After  much  effort  I  crushed 
the  stone  in  situ,  and  then  pulverized  the  fragments  one  by  one,  some  in 
the  pouch,  and  some  in  the  general  cavity  of  the  bladder.  The  central 
portion  of  the  stone,  1^  inches  in  diameter,  was  so  extremely  hard  that 
several  of  my  most  powerful  efforts  with  the  Hthotrite  were  necessary 

5 


66  DIFFICULTIES  AND  COMPLICATIONS 

before  it  was  crushed.  The  operation  lasted  two  laours,  during  which 
85-  ounces  of  chloroform  were  used.  A  small  pedunculated  tumour  the 
size  of  a  small  cherry  was  brought  away  by  the  hthotrite  durmg  the 
operation.  The  patient  was  much  exhausted  after  the  operation,  but 
soon  picked  up  strength.  Surgeon-Major  Seymour  saw  him  with  me  on 
February  24,  when  he  was  sitting  up  in  bed ;  and  on  March  9  he  was 
free  from  urinary  symptoms,  but  weak.  On  June  18  Dr.  Seymour,  who 
took  charge  of  my  work  during  my  holiday,  wrote  me  :  '  That  man  from 
whom  you  removed  that  enormous  stone  came  to  show  himself  the  other 
day.  The  last  time  I  saw  him  he  came  in  a  dooly,  looking  like  an  old 
man  of  70.  Now  he  looks  a  fakly  robust  man  of  40.  I  would  not  have 
believed  such  a  change  possible.  He  is  able  to  walk  as  well  as  ever.'  One 
year  after  the  operation,  February  21,  1893,  this  man  appeared  before  me 
in  hospital  in  perfect  health.  He  informed  me  that  his  wife  had  pre- 
sented him  with  a  daughter  one  month  previously,  though  he  had  lost  aU 
sexual  power  for  several  years  before  the  operation. 

By  the  process  of  chipping  and  scrapmg  above  indicated, 
and  fully  described  later  on,  large  calculi  can  be  reduced  to 
such  a  size  that  they  can  be  caught  and  crushed  by  a  litho- 
trite  which  would  not  originally  lock  on  them.  In  this  way  I 
have  crushed  successfully  in  a  lad  of  fifteen  years  a  stone 
weighing  more  than  3;^  ounces  by  a  No.  9  Hthotrite.  The 
amount  of  manual  labour  required  for  dealing  with  these  large 
calculi  is  excessive.  My  hands  were  often  blistered  and  my  arms 
frequently  ached  for  days  after  performing  litholapaxy  in  one 
of  these  cases.  Great  patience  will  be  required  in  the  various 
manipulations  before  the  stone  is  caught.  As  a  rule,  when 
the  stone  is  large,  the  walls  of  the  bladder  hug  it  closely,  so 
that  the  manoeuvre  referred  to  in  these  cases,  of  injecting 
water  to  separate  the  walls  of  the  bladder  from  the  stone, 
must  be  had  recourse  to  before  the  stone  can  be  grasped  by 
the  lithotrite.  It  will  sometimes  be  found,  also,  in  dealing 
with  large  calculi,  that  though  the  lithotrite  will  not  lock 
should  the  stone  be  first  grasped  by  the  long  axis,  it  will  do  so 
if  this  is  changed  for  the  short  axis  of  the  stone.  This 
manoeuvre  should  always  be  tried  before  abandoning  the  case 
as  unsuitable  for  litholaj)axy.     And  here  I  may  mention  that 


DIFFICULTIES  AND  COMPLICATIONS  67 

experience  has  taught  me  that,  as  a  rule,  a  stone  lies  in  the 
bladder  with  its  long  axis  in  the  antero-posterior  direction. 

There  is  no  pomt  on  which  I  have  laid  more  stress  in  my 
published  writmgs  on  this  subject  than  the  absolute  necessity 
of  completing  the  oiDeration  at  a  smgle  sitting,  no  matter  how 
large  the  stone  may  be.  This  is  the  essential  feature  of  the 
operation.  Amongst  my  610  operations,  in  eight  instances 
only  was  it  necessary  to  have  recourse  to  a  second  sitting,  and 
in  two  cases  only  designedly  so — that  of  a  boy  fifteen  years 
old,  from  whom  I  removed  successfully  a  stone  (or  rather  two 
stones),  the  debris  of  which  weighed  31-  ounces,  the  details  of 
which  will  be  given  later  on ;  the  other,  that  of  a  man  aged 
forty-five,  with  a  large  calculus,  3  ounces  in  weight.  After 
removing  2  ounces  of  debris,  I  had  to  postpone  finishing  the 
operation  to  a  second  sitting,  owing  to  the  extreme  exhaustion 
of  the  patient.  In  this  case  a  fatal  result  ensued  from 
pysemia.  In  the  remaining  six  instances  a  fragment  was 
undesignedly  left  behind  at  the  first  sitting,  revealmg  its 
presence  next  day  by  the  pain,  stoppage  of  urine,  and  other 
symptoms,  when  it  was  removed  at  a  second  sitting. 

Encysted  Calculi. — The  manner  in  which  the  main  portion 
of  the  calculus  referred  to  in  Case  517,  which  lay  m  a 
pouch,  was  disposed  of,  naturally  leads  one  on  to  the  con- 
sideration of  encysted  calculus  of  the  bladder.  In  a  paper* 
which  I  read  at  the  International  Medical  Congress  at  Eome, 
in  1894,  I  called  the  attention  of  the  profession  to  this  subject. 
Previously  such  cases  had,  by  general  consensus  of  opmion, 
been  relegated  to  supra-pubic  lithotomy ;  and  I  am  unaware 
of  any  published  writings  in  which  dealing  with  them  by 
litholapaxy  had  been  advocated.  When  the  opening  into  the 
sac  in  which  the  stone  lies  is  narrow,  or  when  the  stone 
almost  fills  the  pouch,  it  will  be  necessary  to  have  recourse  to 
cystotomy ;  but,  so  far  as  my  experience  goes,  such  cases  are 

*  British  Medical  Journal,  June  16,  1894. 


68  DIFFICULTIES  AND  COMPLICATIONS 

rare,  the  stone  as  a  rule  lying  loosely  in  a  wide-mouthed 
pouch.  For  several  years  I  have  now  been  in  the  habit  of 
dealing  with  encysted  calculi  mostly  by  litholapaxy,  with- 
drawing the  stone  into  the  general  cavity  of  the  bladder  when 
possible  and  crushing  it  there  ;  otherwise  crushing  it  in  the 
sac.  Though  limits  of  space  will  not  permit  of  my  dealing 
exhaustively  with  this  subject  here,  I  will  venture  to  give 
two  typical  examples : 

Case  513. — January  30,  1892,  a  male,  aged  60,  admitted  to  hospital  with 
symptoms  of  stone  of  three  years'  dtiration.  These  had  commenced  with 
severe  kidney  colic.  The  patient  was  so  weak  and  in  such  pain  that  he 
could  not  leave  his  bed.  Passing  blood  and  pus  in  the  urine.  Dysentery 
and  piles  also  present.  On  January  31  I  performed  litholapaxy.  The 
stone  was  felt  to  be  a  large  one,  lying  in  a  sac  on  the  right  side  of  the 
bladder,  about  the  position  of  the  ureteral  orifice.  It  was  found  impossible 
at  first  to  grasp  the  stone,  owing  to  the  walls  of  the  sac  hugging  it  rather 
tightly.  By  injectmg  water  into  the  bladder  by  the  asphator  this  diffi- 
culty was  overcome,  the  stone  being  caught  by  the  lithotrite  in  the  sac. 
I  tried  to  withdraw  it  into  the  bladder,  but  this  could  not  be  effected 
owing  to  the  neck  of  the  pouch  being  too  narrow  ;  so  the  stone  was  crushed 
in  situ.  After  this  the  fragments  were  crushed,  some  in  the  sac  and  some 
in  the  general  cavity  of  the  bladder.  No.  15  lithotrite  and  No.  18  cannula 
were  introduced  several  times  before  the  whole  of  the  debris,  which 
weighed  705  grains,  was  removed.  The  stone  was  mainly  phosphatic. 
After  the  calculus  had  been  removed  I  made  a  survey  of  the  sac  by  means 
of  the  lithotrite.  It  appeared  to  be  egg-shaped,  with  smooth  waUs.  The 
openmg  into  the  bladder  was  circular,  with  a  sharp,  smooth,  weU-defined- 
edge,  and  1^  inches  ua  diameter.  The  depth  of  the  sac  as  felt  by  the 
lithotrite  was  3^  inches.  The  day  after  the  operation  the  patient  was 
sitting  up  in  bed,  free  from  pain  and  passing  urine  freely.  He  said  he  had 
not  felt  so  well  for  two  years.  He  made  a  rapid  recovery,  and  was  dis- 
charged on  February  6. 

Case  557. — K.  B.,  male,  aged  55,  admitted  to  Moradabad  Hospital 
September  20,  1892,  with  stone  of  three  years'  standing.  In  terrible  pain ; 
passhig  pus  and  blood  with  m-ine  ;  prolapse  of  the  bowel  takes  place  from 
straining ;  very  thin  and  anaemic.  On  the  22nd  I  performed  litholapaxy. 
Lithotrite  No.  15  passed  with  difficulty,  owing  to  the  stone  lying  close  to 
the  neck  of  bladder.  On  opening  its  jaws  a  second  stone  was  found  further 
back.  This  was  easily  crushed  and  washed  out.  It  consisted  of  white 
phosphates ;  weight,  317  grains.     I  then  tried  to  catch  the  second  stone 


DIFFICULTIES  AND  COMPLICATIONS  69 

lying  near  the  neck  of  the  bladder,  but  failed  to  do  so.  No.  16  cannula 
was  then  passed  as  far  as  the  stone,  which  seemed  to  be  partly  in  the 
prostatic  urethra,  and  water  injected  from  the  aspirator  with  force,  but  I 
could  not  dislodge  the  stone  backwards.  I  now  introduced  a  No.  8  child's 
lithotrite,  and,  holding  it  perpendicularly,  after  some  manipulation  caught 
the  stone,  which  I  found  was  encysted  in  a  diverticulum,  formed,  as  I 
imagined,  partly  by  the  trigone  and  partly  by  the  posterior  portion  of  the 
base  of  the  prostatic  urethra.  The  stone  was  1^  inches  in  diameter,  so  the 
lithotrite  would  not  lock.  I  then  substituted  a  No.  10  lithotrite,  with 
which  I  crushed  the  stone  in  the  sac  into  large  fragments.  A  No.  16 
camiula  was  next  introduced,  its  end  placed  in  the  sac,  and  a  large  portion 
of  debris  removed  by  the  aspirator.  Some  large  fragments  were  driven 
by  the  inward  current  out  of  the  sac  into  the  main  portion  of  the  bladder. 
Here  they  were  crushed  by  the  lithotrite,  some  further  fragments  being 
crushed  in  the  pouch.  On  opening  the  jaws  of  the  lithotrite  in  the  pouch 
it  was  found  to  be  If  inches  in  diameter.  During  the  operation  I  passed 
my  finger  into  the  rectum  and  felt  the  stone  in  the  pouch  quite  plamly. 
This  second  stone  was  of  dark  urates,  and  weighed  180  grams.  Time 
occupied  by  operation,  55  minutes.  Patient  had  much  scalding  for  a  few 
days,  with  an  attack  of  cystitis,  which  was  treated  by  washing  out  the 
bladder  and  injecting  astringents.  The  urine  was  clear  on  October  1,  and 
the  patient  was  discharged  ciu'ed  on  October  5. 

Urethral  Stricture. — Of  all  the  complications  met  with  in  the 
treatment  of  stone  by  litholapaxy,  the  most  difficult  to  deal 
with  is  perhaps  the  presence  of  organic  stricture  of  the  urethra . 
To  permit  of  the  large  instruments  employed  in  this  operation 
passing  through  the  urethral  canal,  the  stricture  must  first  of 
all  be  disposed  of.  This  will  be  accomplished  by  either  internal 
urethrotomy  or  dilatation,  according  to  the  nature  of  the 
stricture.  If  the  case  be  one  suitable  for  dilatation — that  is 
to  say,  if  the  stricture  be  soft,  elastic,  and  dilatable — this  is 
best  done  by  passing  rapidly  in  succession  a  series  of  conical 
steel  sounds  (Fig.  28)  two  or  three  sizes  larger  at  the  bend 
than  at  the  point,  till  the  canal  is  sufficiently  dilated,  and 
then  at  once  introducing  the  lithotrite  and  disposing  of  the 
stone.  If  the  stricture  be  tight,  but  dilatable,  it  will  be  well 
to  commence  its  dilatation  a  couple  of  days  before  the  operation, 
by  tying  in  gum-elastic  catheters  of  successively  larger  sizes 


70 


DIFFICULTIES  AND  COMPLICATIONS 


till  No.  8  or  10  is  reached,  and  then,  on  the  day  of  the  opera- 
tion, completing  the  dilatation  by  large  conical  steel  sounds 
rapidly  passed  in  succession.     If,  however,  the  stricture  be 


ktTVM.   SIZE 

OF   HEAD 


'J3    SCALE 

Fig.  32.  Fig.  33. 

hard,  cartilaginous,  and  non-dilatable,  it  must  be  dealt  with 
by  internal  urethrotomy  immediately  before  the  operation  for 
the  stone.  The  variety  of  urethrotomy  which  I  almost  in- 
variably perform  is  that   known   as   Civiale's,  in  which  the 


DIFFICULTIES  AND  COMPLICATIONS  71 

stricture  is  cut  from  behind  forwards ;  and  the  form  of 
urethrotome,  Thompson's  modification  of  Civiale's  instrument 
(Fig.  32).  I  cut  thoroughly  through  the  morbid  tissue,  and 
am  not  satisfied  till,  on  withdrawal  of  the  urethrotome,  a  solid 
steel  sound  of  No.  16  or  18  (English)  passes  easily  into  the 
bladder  without  the  use  of  any  force.  Holt's  dilator  (Fig.  33) 
was  formerly  much  employed  for  bursting  strictures  of  this 
nature,  and  there  are  still  some  surgeons  who  cling  to  this 
instrument ;  but  I  merely  refer  to  it  to  condemn  it  as  un- 
scientific and  dangerous,  frequently  bursting  the  healthy  canal 
instead  of  the  stricture.  I  have  for  many  years  abandoned 
this  method  in  favour  of  that  by  internal  urethrotomy. 

The  following  illustrative  cases  will  show  the  manner  in 
which  this  complication  may  be  successfully  dealt  with : 

Case  51. — A  male,  aged  65,  admitted  July  5,  1883,  with  symptoms  of 
stone,  the  presence  of  which  was  confirmed  bj'  the  sound.  The  symptoms  had 
existed  three  years,  and  the  patient  was  extremely  weak.  He  was  carried 
to  hospital  in  a  bed ;  unable  to  stand  or  even  sit  up  without  aid.  There 
was  excruciating  pain  in  passing  water.  He  had  to  pass  urine  every  half 
hour  or  so,  only  a  small  portion  coming  away  at  a  time.  The  urine  was 
blood-stained,  and  mixed  with  pus  and  shreds  of  lymph.  Much  albumen 
present.  On  passing  the  sound  it  was  ascertained  that  there  were  two 
strictures  present,  one  an  inch  behind  the  glans,  and  the  other  4  inches 
from  the  meatus,  through  which  a  No.  6  sound  only  would  pass.  The 
patient  was  suffering  from  fever,  and  so  extremely  weak  that  I  was  afraid 
to  undertake  any  operation ;  admitted  to  hospital  and  placed  under  pre- 
liminary treatment.  On  July  8  there  was  very  little  improvement,  and 
I  determined  to  operate.  The  patient  being  anaesthetized,  the  first 
stricture  was  divided  by  means  of  a  long  narrow  scalpel  passed  along  a 
director,  and  the  meatus,  which  was  narrow,  cut  at  the  same  time.  The 
deep  stricture  was  then  cut  by  means  of  the  urethrotome.  A  full-sized 
hthotrite  was  then  passed,  the  stone  caught  and  crushed,  and  the  debris 
removed  through  a  No.  18  cannula,  which  was  passed  without  difficulty. 
The  stone,  which  was  uric  acid,  weighed  1|  drachms.  The  bladder  felt 
sacculated,  and  a  large  quantity  of  filthy  pus  and  flakes  of  lymph  was 
brought  away  by  the  aspirator  with  the  fragments  of  stone.  The  operation 
lasted  only  ten  minutes.  A  full-sized  gum-elastic  catheter  was  then  tied 
in.  July  9  :  Patient  very  weak ;  suffered  from  high  fever  last  evening ; 
urine  blood-stained  and  mixed  with  pus,  I^July  10  :  Fever  again  last  night ; 


72  DIFFICULTIES  AND  COMPLICATIONS 

very  weak,  and  wanders  in  his  conversation.  July  11  :  No  fever  ;  patient 
much  better,  sitting  up  in  bed ;  urine  clear ;  catheter  removed.  From 
this  time  convalescence  was  rapid,  and  he  was  walking  about  on  July  14. 
Discharged  cm-ed  on  July  20. 

Case  105. — Male,  aged  50,  admitted  into  the  Bareilly  Hospital  Sep- 
tember 10,  1884,  -ndth  symptoms  of  stone,  which  had  existed  four  months. 
Mietmition  very  painful  and  dif&ciilt,  and  fi-equent  stoppage  of  water.  A 
small  sound  passed,  and  stricture  detected  at  the  membraneous  portion  of 
the  uretln-a.  The  patient  being  chloroformed,  internal  urethrotomy  was 
performed.  A  medium-sized  Hthotrite  was  passed,  and  the  stone  crushed. 
The  debris  was  removed  through  a  No.  14  cannula,  and  weighed  15  grains 
only.  A  gum-elastic  catheter  tied  in.  The  patient  made  a  rapid  re- 
covery, and  was  discharged  cured  November  16. 

Case  114. — A  male,  aged  45,  admitted  into  the  Bareilly  CiAil  Hospital, 
October  31,  1884,  suffering  from  symptoms  of  stone,  which  had  existed 
one  year.  On  passing  a  sound,  a  small  stone  was  felt,  and  the  urethra 
was  found  contracted  at  the  membraneous  portion,  admitting  a  No.  10 
sound  -nath  difficulty.  Patient  anaesthetized,  and  a  series  of  sounds  from 
No.  10  to  No.  16  passed  rapidly  one  after  another.  A  medium-sized  hthotrite 
was  then  passed  easUy,  and  the  stone  caught  and  crushed.  The  calculus 
was  mixed,  partly  uric  acid  and  partly  oxalate  of  lime ;  fragments  weighed 

1  drachm  and  20  grains.  Carmula  No.  14  used.  Evening  :  Patient  in 
great  pain ;  passing  urine  by  means  of  catheter  only,  which  was  three 
times  introduced  by  my  Assistant- Surgeon,  and  eventuallj'  a  gum-elastic 
catheter  tied  in.  Poultices  to  the  hypogastrium,  and  hot  fomentations. 
Dover's  powder,  10  grains,  internally.  November  1  :  No  pain ;  passing 
water  freely  through  the  catheter ;  no  fever.  Patient  rapidlj'  recovered, 
and  was  discharged  on  November  12. 

Case  281. — C.  H.,  admitted  November  7, 1888,  with  stone  in  the  bladder 
and  stricture  of  the  m-ethra,  the  latter  of  several  years'  duration.  Health 
extremely  bad,  a  mere  skeleton,  in  fact,  and  so  weak  that  he  could  not 
leave  his  bed.     Two  strictures,  one  at  the  orifice  of  the  urethra,  extending 

2  inches  backwards,  and  a  second  4^  inches  from  the  orifice,  admitting  a 
No.  5  metal  sound,  by  which  the  stone  was  felt  in  the  bladder.  Patient 
put  rmder  preparatory  treatment,  and  on  November  11  a  No.  5  soft 
catheter  tied  in.  Next  day  both  strictures  were  fully  divided  by  the 
urethrotome,  and  a  No.  15  steel  sound  at  once  passed.  The  hthotrite  was 
then  introduced,  the  stone  crushed,  and  evacuated  through  a  No.  14 
cannula.  The  calculus  was  phosphatic — weight,  122  grains.  The  patient 
made  an  uninterrupted  recovery.  On  the  14th  he  was  sitting  up  in  bed, 
on  the  16th  a  No.  14  steel  sound  was  passed,  and  on  the  18th  he  was  dis- 
charged cm-ed. 


DIFFICULTIES  AND  COMPLICATIONS  73 

Case  598. — This  patient  was  operated  on  by  me  on  March  9,  1894,  in 
presence  of  the  students  in  one  of  the  large  London  hospitals,  by  kind 
invitation  of  one  of  the  surgeons  on  the  staff.  A  male,  aged  45,  suffering 
from  stone  and  double  stricture  of  the  urethra,  the  latter  having  existed 
several  years.  Both  strictm-es  being  dilatable,  conical  steel  sounds  were 
passed  rapidly  in  succession  up  to  No.  12  Enghsh.  The  only  larger  sound 
available  was  a  No.  15,  which  Avould  not  pass.  No.  10  hthotrite  was  mtro- 
duced,  but  after  several  imsuccessful  attempts  to  crush  the  stone,  it  was 
withdrawn.  After  some  manipulation  I  managed  to  push  the  No.  15 
sound  through  the  strictures.  A  No.  14  lithotrite  was  then  passed,  the 
stone  crushed,  and  the  debris  removed  through  a  No.  14  cannula.  The 
patient  made  a  rapid  and  unuaterrupted  recovery.  This  patient  appeared 
at  the  same  hospital  a  couple  of  months  ago,  when  he  was  found  to  be  free 
from  stone  and  strictiu'e. 

Hypertrophied  Prostate,  —  Enlargement  of  the  prostate  is 
a  complication  wbich,  contrary  to  what  might  be  expected,  as 
a  rule  offers  little  obstruction  to  the  performance  of  litho- 
lapaxy.  In  passmg  the  instruments  over  the  enlarged  prostate 
a  little  extra  manipulation  may  be  necessary,  and  this  can 
only  be  learnt  with  practice.  When  obstruction  is  met  with 
at  the  prostatic  portion  of  the  urethra,  I  find  the  manipulation 
of  depressing  the  handle  of  the  lithotrite  between  the  thighs, 
and  pushing  it  on  with  a  slight  rotatory,  or  boring,  motion  in 
the  direction  of  the  axis  of  the  body,  frequently  successful  in 
entering  the  bladder.  Should  this  fail,  it  will  be  necessary 
for  the  surgeon  to  change  the  right  side  of  the  patient  for  the 
left,  and,  by  means  of  the  forefinger  of  the  left  hand  in  the 
rectum,  holding  the  lithotrite  in  the  right,  endeavour  to  guide 
the  pomt  of  the  instrument  over  the  obstruction  into  the 
bladder. 

When  considerable  hypertrophy  of  the  prostate  exists,  and 
particularly  when  the  middle  lobe  is  enlarged,  owing  to  its 
projection  into  the  bladder,  there  is  naturally  a  pouch  formed 
between  the  posterior  surface  of  this  organ  and  the  base  and 
posterior  wall  of  the  bladder.  It  is  in  this  pouch  that,  as  a 
rule,  the  stone  lies,  and,  in  order  to  catch  it  there,  it  will  fre- 
quently be  necessary  to  turn  the  jaws  of  the  lithotrite  round 


74  DIFFICULTIES  AND  COMPLICATIONS 

SO  as  to  point  downwards,  and  then  open  them  in  this  posi- 
tion, when,  by  a  Httle  manipulation,  the  stone,  and  subse- 
quently its  fragments,  will  be  caught. 

When  the  enlargement  of  the  prostate  is  accompanied  by 
atony  of  the  bladder,  care  must  be  taken  to  draw  the  urine  off 
three  or  four  times  daily  after  the  operation  by  means  of  a 
catheter,  or  a  soft  rubber  catheter  may  be  tied  in  and  the 
urine  allowed  to  flow  by  this  for  a  few  days. 

There  is  generally  a  good  deal  of  bleeding  during  the  per- 
formance of  litholapaxy  when  the  prostate  is  enlarged.  It  is 
necessary  in  such  cases  to  exercise  great  care  in  removing  the 
last  fragments,  for  they  frequently  get  embedded  in  clots  of 
blood  in  the  bladder,  which  have  to  be  broken  up  by  frequent 
washings  by  the  aspirator,  and  then  removed  with  the  en- 
tangled debris  of  stone. 

The  following  cases  illustrate  some  of  the  difficulties  met 
with,  as  also  the  after-treatment.  Case  123,  already  given 
under  the  head  of  '  Large  Calculi,'  also  illustrates  some  of  the 
difficulties  arising  from  enlarged  prostate,  as  well  as  the  means 
by  which  they  may  be  overcome. 

Case  34. — A  mason,  aged  85,  admitted  April  15,  1883,  with  symptoms 
of  stone,  which  had  existed  two  years.  There  was  great  pain  in  passing 
urine,  which  came  away  in  small  quantities  at  a  time,  frequently  repeated. 
On  passing  a  sound,  the  presence  of  a  stone  was  confirmed,  and  the  exist- 
ence of  a  greatly  enlarged  prostate  also  ascertained.  On  passing  a  cathe- 
ter, a  large  quantity  of  residual  urme  was  drawn  off.  The  patient  was 
emaciated,  extremely  feeble,  and  almost  in  a  dying  state.  Still,  he  was 
at  once  anaesthetized,  and  litholapaxy  performed.  There  was  considerable 
difficulty  at  first  experienced  in  passing  the  lithotrite  over  the  prostate. 
This  was  obviated  by  passing  the  instrument  on  the  left  side,  with  the 
finger  in  the  rectum  as  a  guide.  The  operation  lasted  twenty  minutes, 
during  which  6|  drachms  of  a  very  hard  uric-acid  calculus  were  removed. 
The  lithotrite  had  to  be  introduced  four  times,  and  a  No.  16  catheter  as 
often.  Evening  :  Eetention  of  urine ;  catheter  passed  and  water  drawn 
off ;  patient  suffering  from  high  fever,  very  weak.  16th  :  Fever  less  ; 
retention  of  urme  continues ;  catheter  passed  every  six  hours.  19th :  On 
passing  the  catheter  it  grated  against  a  fragment  of  stone.     Chloroform 


DIFFICULTIES  AND  COMPLICATIONS  75 

given,  and  the  fragment  crushed  and  evacuated  by  the  asphator  ;  weight 
40  grains.  From  this  time  the  patient  made  a  rapid  recovery,  putting  on 
flesh  and  picking  up  strength,  and  was  discharged  cured  of  stone  on 
April  26. 

Case  379.— E.  B.,  aged  75,  admitted  to  the  Moradabad  Hospital, 
April  14,  1890,  with  large  stone  of  six  years'  standing.  Extremely  weak 
and  in  great  pain ;  passing  urine  every  fifteen  minutes,  frequently  mixed 
with  blood.  Prostate  much  enlarged.  Litholapaxy  performed  April  15. 
I  introduced  my  largest  Uthotrite,  No.  18,  and  at  once  caught  the  stone, 
but  found  I  could  make  no  impression  on  it.  Eventually  one  end  of  the 
stone,  which  was  oval,  was  caught,  and  with  a  great  effort  broken  off. 
This  was  then  reduced  to  debris,  and  removed  by  the  aspurator.  This 
process  was  repeated  again  and  again  till  the  whole  stone  was  disposed  of. 
There  was  considerable  bleeding  during  the  operation  from  the  enlarged 
prostate,  but  the  patient  bore  the  operation,  which  lasted  an  hom-  and  a 
quarter,  weU.  The  debris  was  that  of  an  oxalate  of  limestone,  and 
weighed  3|  ounces.  Evening  :  Patient  wonderfully  well ;  passing  urine 
freely,  slightly  coloured  with  blood.  No  fever;  slight  pain  in  the 
perineum,  relieved  by  hot  fomentations.  Nest  day  the  urine  was  clear. 
April  20:  Walking  about,  free 'from  all  urinary  sjTxiptoms.  Discharged 
April  27,  in  excellent  health. 

Becent  Case.—F.  H.,  aged  54,  patient  of  Dr.  Macnaughton  Jones,  of 
Harley  Street,  with  whom  I  saw  the  case  in  consultation,  April  21,  1896. 
Suffering  for  four  years  from  kidney  colic,  gravel,  and  bloody  uruae,  for 
which  he  went  to  Contrexeville  on  three  different  occasions,  each  time 
with  temporary  rehef.  About  a  year  ago,  in  rushing  down  hill  to  catch  a 
train,  felt  something  distm-bed  in  his  bladder.  Next  day  passed  bloody 
urine  and  a  substance  '  reserubhng  a  mixture  of  chocolate  and  mortar.' 
Ever  since  has  had  difficulty  of  mictm-ition,  with  twisted  stream  and 
sense  of  obstruction  at  the  neck  of  bladder.  Has  passed  large  quantities 
of  blood  during  past  four  months.  There  is  great  kritabOity  of  bladder  ; 
urine  passed  every  horn-.  Pain  before,  during,  but  especially  after  micturi- 
tion. Urine  contains  much  blood  and  thick  stringy  mucus.  Prostate 
much  eixlarged;  Coudee  catheter  passed  four  times  daily  for  some  months. 
Patient  w-rites :  '  The  last  tw^o  or  three  weeks  life  has  been  a  torment. 
Could  not  rise  from  seat  without  desire  to  make  water.  Could  make  only 
a  small  quantity,  then  stoppage,  and  then  only  in  spu'ts,  finishing  with 
severe  cutting  and  twisting  pains.'  Dr.  Macnaughton  Jones  diagnosed  a 
stone  in  the  bladder,  the  presence  of  which  was  confirmed  at  our  consulta- 
tion. On  April  25  I  performed  htholapaxy,  Dr.  Macnaughton  Jones  being 
present  and  Dr.  Dudley  Buxton  gi%^ng  ether.  No.  15  lithotrite  was  passed 
with  great  ease  as  far  as  the  prostate,  where  some  manipulation  was 
necessary  to  enter  the  bladder.     The  stone,  which  lay  in  a  pouch,  or  bed, 


76  DIFFICULTIES  AND  COMPLICATIONS 

formed  behind  the  prostate,  was  quickly  grasped  (measui'mg  1^  inches) 
and  crushed,  and  the  debris  removed  through  a  No.  16  cannula.  The 
stone  was  moderately  hard,,  consisting  mainly  of  phosphate  of  lime  with 
uric  nucleus ;  weight  344  grains.  The  bladder  was  extremely  narrow, 
contracted,  with  thick,  rough,  rigid  walls.  Instruments  twice  introduced, 
operation  lasting  fifteen  mmutes.  Some  bleeding  from  the  prostate ;  the 
wasMngs  brought  away  much  filthy  mucus  and  thick  flakes  of  lymph 
with  the  debris  of  stone.  The  patient  had  not  one  bad  symptom,  and 
made  a  rapid  recovery,  being  dressed  and  walking  about  his  room  on 
April  27,  two  days  after  operation !  The  patient's  progress  may  best  be 
given  in  his  own  words,  written  on  AprU  30 :  'No  after  pains  or  mcon- 
venience  whatever.  Second  day  after  operation  water  became  clearer,  and 
thu'd  day  quite  clear.  Can  now  retain  water  in  a  normal  manner  day 
and  night.  Was  in  bed  two  days  by  doctor's  wish,  though  feeling 
no  necessity  for  it,  and  had  at  no  time  any  sensations  reminding  me  of 
operatioru'  On  April  30  I  examined  the  prostate,  and  found  that  it  had 
greatly  diminished  in  size,  thus  illustrating  what  I  have  frequently  verified 
in  my  practice — that  the  presence  of  a  stone  in  the  bladder  will  often 
cause  congestive  or  inflammatory  turgescence  of  an  abeady  enlarged 
prostate,  which  quickly  subsides  if  the  stone,  the  source  of  irritation,  be 
completely  removed.  On  May  1  the  patient  went  for  a  long  walk,  and 
next  day  returned  to  his  business  in  the  City. 

I  had  the  pleasure  of  showing  this  case  to  some  well-known  surgeons, 
who  expressed  surprise  at  the  rapidity-  of  the  cm:e.  The  case  was  a 
typical  example  of  stone  comphcated  with  enlargement  of  the  prostate, 
chronic  cystitis,  and  contracted,  nregular  bladder  with  thickened,  rigid 
walls,  giving  little  room  for  the  manipulation  of  instruments,  which  some 
of  my  London  surgical  friends  think  a  peculiar  feature  in  Enghsh  practice, 
but  which  I  can  assure  them  in  no  way  dififers  from  similar  cases  in  one's 
practice  in  India.  I  was  pleased  to  meet  with  a  comphcated  case  of  this 
kind  thus  early  m  my  London  career ;  and  whether  regard  be  had  to  the 
difliculties  encountered,  the  ease  with  which  they  were  overcome,  or  the 
rapidity  of  the  cure,  I  shall  have  no  objection  to  meeting  with  many  such 
cases. 

We  must  not  expect,  however,  to  be  successful  in  performing 
litholapaxy  in  every  case  in  which  hypertrophy  of  the  prostate 
occurs  in  connection  with  stone  in  the  bladder.  It  will  occa- 
sionally be  found  that,  even  when  a  large  steel  sound  can  be 
passed  readily  into  the  bladder  in  such  cases,  no  amount  of 
manipulation  will  enable  us  to  pass  a  lithotrite,  with  its 
sharply  curved  beak.    The  use  of  force  of  any  kind  in  passing 


DIFFICULTIES  AND  COMPLICATIONS  77 

instruments  in  such  cases  must  be  carefully  avoided ;  and  if 
the  lithotrite  cannot  be  coaxed  in  by  that  amount  of  manipu- 
lative skill  which  the  surgeon  from  his  experience  has  acquired, 
the  idea  of  performing  litholapaxy  must  be  abandoned,  and 
supra-pubic  or  perineal  lithotomy  had  recourse  to,  according 
to  the  circumstances  of  the  case. 

I  may  mention  here  that  hypertrophy  of  the  prostate  occurs 
at  a  much  earlier  age  amongst  natives  of  India  than  amongst 
Europeans,  being  frequently  found  amongst  them  as  early  as 
45  years.  But  then  it  must  be  recognized  that  the  expectation 
of  life  is  at  least  ten  years  less  amongst  Asiatics  than  amongst 
Europeans,  and  that  a  native  of  India  is  comparatively  as  old 
at  45  as  a  European  at  55. 

Partially  Impacted  Calculus. — A  difficulty  is  sometimes  met 
with,  both  in  passing  the  instruments  and  catching  the  stone, 
when  the  calculus  lies  stationary,  growing  partly  in  the 
bladder  and  partly  in  the  prostatic  portion  of  the  urethra. 
From  one's  experience  of  lithotomy,  the  difficulty  of  managing 
such  cases  may  be  easily  imagined.  Every  lithotomist  of  any 
experience  must  have  come  across  cases  in  which  an  irregular, 
elongated  calculus  lies  with  its  main  portion,  or  body,  in  the 
bladder,  and  a  small  elongated  head  in  the  prostatic  urethra, 
the  two  portions  being  united  by  a  neck  corresponding  with 
the  vesical  orifice  of  the  urethra.  Such  a  calculus  must,  if 
possible,  be  displaced  from  its  position  backwards  into  the 
bladder  before  being  crushed,  otherwise  lithotomy  will  have  to 
be  performed.  The  manner  of  dealing  with  such  calculi  will 
be  best  illustrated  by  a  case  from  actual  practice  : 

Case  121. — This  case  I  saw  in  consultation  with  Surgeon-Major  Fasken, 
at  Dehra  Doon,  with  whose  kind  permission  I  performed  htholapaxy.  A 
Huidoo,  aged  32,  admitted  March  17,  1885,  with  stone,  which  had  existed 
five  years.  Patient  very  thin  and  weak  ;  passed  urine  in  drops  with  great 
pain.  On  the  20th,  chloroform  being  given  by  Dr.  Fasken,  I  operated. 
On  passing  a  full-sized  sound,  the  stone  was  met  with  at  the  neck  of  the 
bladder,  and  obstructed  its  advance,  but  by  manipulation  the  sound  was 


78  DIFFICULTIES  AND  COMPLICATIONS 

passed  into  the  bladder  over  the  stone.  The  same  difficulty  was  ex- 
perienced in  passing  the  Hthotrite,  and  the  stone  could  not  be  grasped. 
The  Hthotrite  was  therefore  withdrawn,  a  No.  18  cannula  introduced  as 
far  as  the  end  of  the  stone  lying  in  the  prostatic  urethra,  the  aspirator 
apphed.  and  water  pumped  with  force  into  the  bladder.  By  this  manoeuvre 
the  stone  was  displaced  backwards  into  the  bladder  by  the  force  of  the 
stream,  the  prostatic  m-ethra  grasping  the  stone  being  at  the  same  time 
dilated  by  the  water,  and  so  loosening  its  hold  on  the  stone.  The  stone 
was  then  grasped  by  the  hthotrite,  and  soon  disposed  of.  The  operation 
lasted  twenty-three  minutes,  the  debris  of  the  stone,  which  was  mixed  m-ic 
acid  and  phosphates,  weighing  5|-  drachms.  There  was  some  pain  in  the 
m-ethi"a  for  a  day  or  two,  with  some  dribbling  of  water,  but  the  patient  was 
discharged  on  April  3rd  perfectly  well. 


CHAPTER  VI. 

LITHOLAPAXY  IN  MALE  CHILDREN  AND  IN 
FEMALES. 

The  present  chapter  will  deal  mainly  with  the  peculiarities  of 
litholapaxy  as  applied  to  male  children,  some  brief  remarks 
being  added  on  the  operation  in  females  of  all  ages. 

Male  CMldren. — It  was  not  till  1886,  fom-  years  after  I  had 
commenced  to  perform  litholapaxy  in  adult  males,  that  I 
extended  the  operation  to  male  children.  Though  an  ardent 
advocate  of  the  operation  in  the  adult  male  and  females  of  all 
ages,  I,  like  most  other  surgeons,  at  first  opposed  its  extension 
to  the  case  of  male  children,  basing  my  opposition  on  the  un- 
developed condition  of  the  genito-urinary  organs — the  bladder 
being  small,  the  urethra  narrow,  and  the  mucous  membrane 
sensitive  and  liable  to  laceration.  On  the  other  hand,  perineal 
lithotomy  in  the  child  had  always  been  a  comparatively  suc- 
cessful operation ;  and,  so  far  as  my  own  experience  of  it  was 
concerned,  I  had  no  reason  in  this  respect  to  abandon  this 
operation  in  favour  of  litholapaxy,  having,  before  adopting 
litholapaxy  in  such  cases,  performed  145  lithotomies  in  male 
children  without  a  death.  I  may  mention  that  I  have  now 
performed  197  lithotomies  in  male  children  with  only  one 
death.  In  fact,  I  had  the  good  fortune  of  having  performed 
191  successful  consecutive  lithotomies  in  children  before  a 
fatal  case  occurred.    In  spite  of  this  success,  however,  I  was  so 


8o  LITHOLAPAXY  IN  MALE  CHILDREN  AND  IN  FEMALES 

much  impressed  by  the  results  of  Htholapaxy  in  male  children 
announced  by  Keegan  in  two  very  able  and  interesting  papers 
published  in  the  Indian  Medical  Gazette  in  1885,  that  I  at 
once  ordered  the  necessary  instruments,  and  decided  on  giving 
the  operation  a  trial.  Since  that  time  I  have  performed 
Htholapaxy  in  male  children  165  times  with  two  deaths. 
My  first  119  cases  were  all  successful,  and  I  had  then  the 
misfortune  of  losing  two  cases  consecutively.  Full  details 
of  my  first  115  cases  were  given  in  three  papers  in  the  British 
Medical  Journal*  All  our  foregone  theoretical  objections  to 
this  operation  in  case  of  male  children  have  vanished  into 
thin  air  when  pitted  against  the  stern  reality  of  accomplished 
facts.  Notwithstanding  the  great  success  I  have  had  with 
lithotomy,  I  have  now  abandoned  the  operation  in  favour  of 
Htholapaxy,  owing  to  the  two  great  advantages  that  the  latter 
possesses — rapidity  of  cure,  and  avoidance  of  a  cutting  opera- 
tion. '  The  greater  my  experience  of  Htholapaxy  in  male 
children  becomes,  the  more  I  am  fascinated  by  the  operation. 
In  most  instances  the  little  patients  may  be  seen  playing 
about  the  day  after  the  operation,  untroubled  by  any  urinary 
symptom.  To  Keegan  is  due  the  honour  of  having,  in  the 
face  of  strong  opposition  and  prejudice,  shown  that  Hthola- 
paxy in  male  children  is  both  feasible  and  safe  ;  and  I  feel 
proud  that  this  honour  has  fallen  to  a  brother  officer,  of  the 
Indian  Medical  Service,  a  Service  which  has  done  so  much  to 
popularize  and  extend  Bigelow's  operation. 

For  the  performance  of  Htholapaxy  in  male  children,  it  is 
essential  that  the  surgeon  should  be  provided  with  a  series  of 
small  fully-fenestrated  lithotrites  (Fig.  34)  of  the  same  patterns 
as  those  used  for  adults,  but  varying  in  size  from  No.  5 
to  10.  It  will  be  found  that  in  boys  aged  from  13  to  16  years 
a  lithotrite  of  size  No.  11  or  12  will  pass  readily  as  a  rule. 
The  cannula  (Fig.  35)  employed  are  also  similar  in  shape  to 

*  December  24,  1887  ;  October  12,  1889  ;  May  9,  1891. 


LITHOLAPAKY  IN  MALE  CHILDREN  AND  IN  FEMALES   8i 


those  used  for  the  adult,  but  vary  in  size  from  No.  6  to  12, 
English  scale.  The  smaller  sizes  should  be  not  more  than 
7  inches  in  length,  as  the  return  stream  through  these  small 


FULL  SIZE 


Fig.  34. 


cannulae  is  very  weak,  and  diminishes  in  strength  with  the 
length  of  the  tube.  The  aspirator  is  the  same  as  for  adults ; 
but  it  must  of  course  be  worked  very  gently,  only  a  small 

6 


82  LITHOLAPAXY  IN  MALE  CHILDREN  AND  IN  FEMALES 

quantity  of  water  proportional  to  the  size  of  the  bladder  being 
thrown  in.     Any  smaller  or  weaker  apparatus  will  not  suffice 


Vm\     FULL  SIZE 


Fig.  35. 


to  extract  debris  through  the  narrow  cannulas,  owing  to  the 
stream  being  so  feeble. 

It  will  be  found  that  the  capacity  of  the  urethra  in  patients 
of  the  same  age  varies  much  more  in  children  than  in  adults. 


LITHOLAPAXY  IN  MALE  CHILDREN  AND  IN  FEMALES  83 

Keegan  was  the  first  to  call  attention  to  this  fact,  which  I 
have  frequently  verified  in  my  practice.  Thus,  the  urethra  of 
a  child  of  5  or  6  years  of  age  will  frequently  be  found  to  admit 
a  No.  10  lithotrite  with  ease  ;  in  other  instances  a  No.  6  is 
passed  with  difficulty. 

The  meatus  of  the  urethra  in  children  is,  as  a  rule,  very 
narrow,  and  almost  mvariably  requires  to  be  enlarged  to 
permit  the  litholapaxy  instruments  to  pass.  The  incision 
should  be  on  the  floor  of  the  urethra. 

I  find  that  in  children,  after  the  meatus  has  been  enlarged, 
the  first  two  inches  of  the  urethra  is,  as  a  rule,  the  narrowest 
and  most  difficult  part  through  which  to  pass  the  lithotrite ; 
whereas  in  adults  the  difficulty,  when  one  occurs,  lies 
generally  at  the  triangular  ligament  or  prostatic  portion  of 
the  canal. 

In  children  the  operation  is,  for  the  same  size  of  stone,  a 
much  more  tedious  one  than  in  the  adult,  owing  to  the  small 
size  of  the  instruments  employed,  and  the  necessity  to  grind 
the  calculus  into  very  fine  debris  before  it  will  pass  through 
the  cannulas. 

There  is  more  danger  of  a  fragment  of  stone  being  left 
behind  in  children  than  in  adults.  The  stream  passing  through 
the  small  tubes  employed  has  not  the  same  evacuatmg  force 
as  in  the  large  cannulse  used  m  adults.  The  debris  is  not, 
therefore,  carried  with  the  same  certainty  towards  the  eye  of 
the  cannula  from  the  various  parts  of  the  bladder ;  and  the 
fragments  do  not  give  out  the  diagnostic  clicking  sound  so 
clearly.  It  is  therefore  necessary  to  institute  a  very  careful 
search  by  pumping  in  water  and  exhausting  it,  with  the  eye 
of  the  cannula  turned  in  various  directions,  before  the  instru- 
ments are  finally  withdrawn.  In  the  hands  of  a  careful  and 
experienced  surgeon  there  is  little  chance  of  a  fragment  being 
left  behind. 

Litholapaxy  should  not  be  attempted  in  a  child  when  the 


84  LITHOLAPAXY  IN  MALE  CHILDREN  AND  IN  FEMALES 

smallest  lithotrite  at  hand  is  a  tight  fit  for  the  urethra. 
When  the  instruments  fit  tightly  at  first,  there  may  be  some 
difficult}^  in  their  re-introduction,  or  even  in  their  withdrawal, 
owing  to  the  congestion  and  swelling  of  the  urethral  mucous 
membrane  that  takes  place  near  the  meatus.  I  have  noticed 
this  phenomenon,  but  to  a  much  slighter  extent,  in  young 
adults,  but  never  in  old  men. 

When  the  urethra  in  a  male  child  is  capacious,  and  the 
calculus  of  moderate  size,  litholapaxy  can  be  performed  with 
facility  ;  but  when  the  urethra  is  very  narrow,  or  the  stone 
large,  the  operation  is  a  difficult  one.  In  any  case,  lithola- 
paxy in  male  children  is  a  much  more  delicate  one  than  in 
the  adult.  I  do  not  think  that  a  surgeon  would  be  at  all 
justified  in  attempting  this  operation  in  a  male  child  till  he 
had  had  very  considerable  experience  of  it  in  the  adult. 

If  it  was  necessary  to  caution  the  surgeon  against  the  use 
of  force  in  passing  instruments  in  the  adult,  this  is  doubly 
necessary  in  the  case  of  children,  in  whom  the  mucous  mem- 
brane and  other  tissues  are  so  delicate  and  easily  lacerated. 

Keegan  writes  :*  '  Uiiquestionahlij  the  best,  and  indeed  the 
only  perfectly  safe,  form  of  lithotrite  to  me  in  performing  lithola- 
paxy in  young  hoys  is  the  completely  fenestrated  pattern  of 
lithotrite.  A  partially  fenestrated  lithotrite  is  liable  to  get 
clogged  with  debris,  and  may  sometimes  retain  within  its 
blades  a  thin  sharp  projecting  fragment  of  stone,  which  may 
lacerate  the  urethra  on  the  withdrawal  of  the  lithotrite  from 
the  bladder.  Clogging  of  the  blades  of  a  lithotrite  with 
debris  is  a  very  dangerous  complication  in  performing  litho- 
lapaxy in  male  children,  because  it  has  the  effect  of  increasing 
the  size  of  the  lithotrite,  say,  from  a  No.  7  to  a  No.  8.  And 
as  in  performing  litholapaxy  in  male  children  we  are  dealing 
with  urethrte  m  which  there  is,  so  to  speak,  not  much  spare 
room  left  to  work  in,  the  effect  of  mcreasing  the  size  or 
*  Lancet,  December,  1886. 


LITHOLAPAXY  IN  MALE  CHILDREN  AND  IN  FEMALES  85 

number  of  the  lithotrite  may  be  such  that  in  its  withdrawal 
from  the  bladder  the  urethra  may  get  unduly  stretched  or 
ruptured.  Now,  it  is  impossible  that  clogging  can  occur 
between  the  blades  of  a  completely  fenestrated  lithotrite. 
Objecting  to  the  employment  of  a  partially  fenestrated  litho- 
trite in  performing  litholapaxy  in  male  children  for  the  reason 
already  stated,  I  can  only  characterize  the  use  of  a  flat-bladed 
unfenestrated  instrument  in  operating  on  this  class  of  patients 
as  unwarrantahle  and  absolutely  dangerous.''  In  these  remarks 
I  entirely  concur. 

The  youngest  child  on  whom  I  have  performed  litholapaxy 
was  one  aged  18  months,  the  details  of  which  are  as  follows : 

Case  276. — A  male  child,  aged  18  months,  admitted  to  the  Moradabad 
Hospital,  November  2,  1888,  with  symptoms  of  stone  of  two  months' 
standing.  On  passing  a  sound  a  faint  click  was  heard.  Nest  day  I  per- 
formed litholapaxy  in  presence  of  Surgeon-General  W.  R.  Rice.  A  No.  5 
lithotrite  passed  with  the  greatest  ease,  and  the  tiny  stone  was  at  once 
caught  and  crushed,  and  evacuated  through  a  No.  6  cannula.  In  with- 
drawing the  lithotrite  some  difficulty  was  experienced,  owing  to  congestion 
and  spasm  of  the  urethra.  The  operation  lasted  eight  minutes,  and  the 
debris  (urates)  weighed  3  grains.  I  saw  the  child  in  the  evening,  and  he 
was  passing  urine  freely  and  without  pain.  Next  day  he  was  quite  well. 
On  the  5th,  two  days  after  the  operation,  the  child  was  taken  to  the  rail- 
way station,  in  order  that  Dr.  Eice,  who  was  passing  through,  raight  see 
him.  Dr.  Eice  expressed  much  surprise  and  pleasure  at  the  rapid  cure  in 
a  child  of  this  age. 

This  is,  as  far  as  I  am  aware,  the  youngest  child  on  whom 
litholapaxy  has  as  yet  been  performed ;  but  the  facility  with 
which  the  instruments  were  introduced  convinces  me  that  the 
modern  operation  is  practicable  in  even  younger  children.  In 
this  connection  I  may  mention  that  on  June  7,  1889,  a  male 
child,  9  months  of  age,  was  brought  to  me  with  symptoms  of 
stone,  but  in  whom  no  stone  was  found.  In  this  case  I  passed 
a  No.  6  cannula,  and  washed  out  the  bladder  by  the  aspirator 
for  diagnostic  purposes.  Had  there  been  a  stone  present  I 
could  have  removed  it  by  litholapaxy  readily.     Keegan  also 


86  LITHOLAPAXY  IN  MALE  CHILDREN  AND  IN  FEMALES 

records*  the  case  of  a  child,  11  months  old,  m  which  he  passed 
a  No.  7  cannula,  and  washed  out  the  bladder  for  diagnostic 
purposes.  So  that  litholapaxy  is  now  practicable  in  children 
of  the  most  tender  ages. 

I  will  now  give  some  instances  of  large  calculi  removed 
from  male  children  by  means  of  small  lithotrites : 

Case  252. — H.  U.,  male  child,  aged  9,  admitted  to  Moradabad  Hospital, 
May  23,  1888,  with  symptoms  of  stone  of  four  years'  standing.  Extremely 
emaciated  and  suffering  from  fever.  Urine  passed  in  drops  every  few 
minutes  with  great  pain.  Child  danced  with  agony,  rolled  about  on  the 
floor,  and  screamed  with  pain  when  he  attempted  to  micturate.  Prepuce 
inflamed  and  ulcerated — ^result  of  the  child  rubbing  it  to  reheve  pain. 

On  May  25  I  performed  litholapaxy.  No.  8  hthotrite  passed  with  ease, 
and  stone  at  once  grasped ;  but  as  it  was  found  to  measure  \\  inches  in 
diameter,  the  lithotrite  would  not  lock.  This  diameter  was  then  changed 
for  a  shorter  one,  on  which  tlie  lithotrite  locked  ;  but  the  stone  was  so 
hard  that  the  lithotrite  failed  to  crush  it.  I  then  grasped  the  stone  by  one 
end,  and  after  some  manipulation  broke  off  a  portion.  This  was  then 
reduced  to  fine  debris  and  evacuated  through  a  No.  10  cannula.  The 
lithotrite  was  again  introduced,  another  portion  of  the  stone  chipped  off, 
and  treated  m  a  similar  manner.  This  process  was  continued,  and  varied 
from  time  to  time  by  scrapmg  the  sides  of  the  stone  by  the  jaws  of  the 
hthotrite,  till  the  whole  stone  was  disposed  of,  the  operation  lasting  two 
hours  and  five  minutes.  The  stone  was  extremely  hard,  composed  of 
carbonate  of  lime,  and  the  debris  weighed  765  grains.  The  hthotrite  was 
introduced  fourteen  times,  and  the  caimula  some  sixteen  or  eighteen 
times  ;  yet  there  was  scarcely  a  trace  of  blood  seen  dm-mg  the  operation. 

"When  I  commenced  this  operation  I  had  no  idea  that  the  calculus  was 
so  large  and  hard,  and  I  must  confess  that  during  its  progress  I  had  grave 
misgivings  as  to  the  advisabihty  of  continmng  it,  the  child  was  so  weak, 
the  stone  so  hard  and  large,  and  the  operation  so  prolonged.  Still  I 
persisted  till  the  whole  stone  was  removed.  The  child  was  extremely 
exhausted,  and  did  not  regain  consciousness  for  two  or  three  hours  after 
the  operation.  Shght  fever  m  the  evenmg,  but  none  next  day.  On  the 
27th  I  had  the  pleasure  of  showing  the  case  to  Surgeon-Major  E.  Drury. 
The  child  was  sitting  up  m  bed,  quite  well  and  happy.  On  June  6  the 
child  was  discharged  cured,  and  was  brought  to  the  hospital  on  June  12 
in  excellent  health. 

Case  288. — Male  child,  aged  10  years,  admitted  December  7,  1888,  with 
*  Lancet,  December,  1886. 


LITHOLAPAXY  IN  MALE  CHILDREN  AND  IN  FEMALES    87 

stone  of  one  year's  duration.  Health  very  bad.  Litholapaxy  performed 
next  day.  The  largest  hthotrite  I  could  introduce  was  a  No.  5,  with  which 
the  stone  was  easily  caught,  but,  owing  to  its  size,  the  instrument  would 
not"  lock.  Time  after  tune  I  grasped  the  sides  of  the  stone  and  then 
screwed  home  the  Hthotrite,  thus  scraping  off  portions  of  the  crust.  In 
this  way  the  stone  was  eventually  reduced  to  such  a  size  that  the  hthotrite 
locked  on  it,  when  it  was  crushed.  The  operation  lasted  sixty-five  mmutes, 
and  the  debris  (uric)  weighed  275  grains.  Child  much  exhausted  ;  passed 
no  urine  till  evening,  when,  under  the  mfluence  of  hot  fomentations  to  the 
perineum  and  loins,  a  copious  flow  of  blood-stained  urine  came  away.  On 
the  10th  the  child  was  sittmg  up  in  bed,  and  on  the  15th  he  was  discharged 
cured. 

Case  605. — Male  child,  aged  10,  admitted  to  Prince  of  Wales  Hospital, 
Benares,  January  23,  1895,  with  stone  of  three  years'  duration.  Suffering 
great  pain  ;  passing  blood  and  pus  in  urine,  which  was  passed  involuntarily 
every  few  minutes.  Litholapaxy  performed  at  once.  Surgeon- Colonel 
Anthonitz  and  Sxu'geon-Captain  Paterson  being  present.  No.  8  hthotrite 
passed  and  stone  caught  at  once,  but  as  the  diameter  was  If  inch,  the 
instrument  would  not  lock.  Even  the  shortest  diameter  was  more  than 
the  capacity  of  the  hthotrite.  The  scraping  and  chipping  process 
described  in  Case  252  was  resorted  to,  the  instrument  being  introduced  at 
least  a  dozen  times  before  the  stone  was  disposed  of.  No.  10  cannula 
used.  The  stone  was  uric,  with  oxalate  of  Hme  nucleus,  and  the  debris 
weighed  340  grains.  Child  very  weak  after  the  operation,  and  continued 
to  dribble  urine  for  three  or  four-  days,  but  was  perfectly  well  on 
February  1,  when  discharged. 

These  cases  illustrate  the  great  variation  in  the  capacity  of 
the  urethra  in  children  of  about  the  same  age,  already  referred 
to.  In  Cases  252  and  605  a  No.  8  Hthotrite  and  No.  10 
cannula  passed  with  ease,  whereas  in  Case  288  the  largest 
instruments  that  could  be  introduced  were  a  No.  5  Hthotrite 
and  a  No.  6  cannula.  They  well  illustrate  the  process  of 
'  scraping  and  chipping ' — if  I  may  so  call  it — by  which  a 
Hthotrite  may  be  made  to  crush  a  stone  of  larger  size  than 
that  for  which  the  instrument  was  constructed.  In  this  way 
comparatively  large  stones  may  be  disposed  of  by  small  litho- 
trites,  a  matter  of  great  significance  when  we  have  to  deal  with 
narrow  urethrse  in  children.  The  process  of  scraping  the 
sides  of   a   stone  is   a   very   tedious   and   delicate  one,  and 


88  LITHOLAPAXY  IN  MALE  CHILDREN  AND  IN  FEMALES 

demands  much  care,  patience  and  perseverance  for  its  success- 
ful accomplishment. 

The  following  is  a  very  remarkable  case  from  various 
aspects,  so  I  will  give  it  in  detail. 

Case  350. — A  Mahomedan  boy,  aged  15,  admitted  to  the  Moradabad 
Hospital,  December  24,  1890,  with  symptoms  of  stone  of  four  years' 
d;iration.  So  miserably  weak  that  he  was  unable  to  walk  or  even  to  stand 
up  ;  in  constant  agonising  pain,  the  urine  passing  in  drops  continually. 
Foreskin  ulcerated,  the  result  of  the  patient  pulling  at  it  to  relieve  pain. 
Spleen  enormously  hypertrophied,  measuring,  roughly,  1  foot  long  by  10 
inches  broad,  and  literally  filling  the  abdomen.  Had  suffered  from  fever 
for  several  months ;  very  anaemic,  with  pinched,  anxious  face.  The  lad 
was  a  living  skeleton,  and  presented  a  miserable  spectacle,  the  result  of 
long  suffering.  Large  stone  of  irregular  shape  felt  by  the  sound.  The 
supra-pubic  operation  suggested  itself,  but  a  cuttmg  operation  of  any  kind 
was  out  of  the  question,  owing  to  the  wretched  health  of  the  lad.  Placed 
under  preparatory  treatment. 

On  December  26  I  performed  litholapaxy  (Surgeon-6aptain  S.  F.  Freyer 
present).  The  largest  lithotrite  that  would  pass,  after  incising  the  floor  of 
the  vieatus,  was  a  No.  9,  and  the  largest  cannula  a  No.  12.  Stone  easily 
caught,  but  too  large  for  lithotrite  to  lock  on  it.  By  the  process  of 
chipping  and  scraping,  I  eventually  reduced  the  stone  to  such  a  size  that 
the  lithotrite  locked  on  it.  It  was  fortunate  that  the  stone  was  irregular 
in  shape  and  not  very  hard,  which  much  facihtated  the  crushing.  The 
lithotrite  and  cannula  were  each  several  times  introduced,  and  after 
working  for  oiae  hour  I  imagined  I  had  completely  emptied  the  bladder  of 
stone,  having  removed  a  mass  of  debris  which  I  roughly  estimated  to 
weigh  nearly  2  ounces.  On  careful  examination  I  found,  however,  that 
there  was  a  tumour,  elongated  in  shape,  in  the  right  groin.  This  I  found 
to  be  a  second  calculus,  situated  in  a  pouch,  apparently  in  the  line  of  the 
ureter.  The  outhne  of  the  stone  could  be  seen  through  the  abdomen ; 
and  it  could  be  felt  in  position  between  a  finger  introduced  into  the 
rectum  and  a  hand  placed  on  the  abdomen.  On  natroducing  the  hthotrite 
I  could  touch  the  lower  end  of  the  stone,  which,  however,  could  neither 
be  grasped  nor  displaced  from  its  bed.  The  patient  was  much  exhausted 
from  chloroform ;  so  he  was  put  to  bed,  my  intention  being  to  remove 
the  second  stone  by  supra-pubic  lithotomy  should  the  boy  recover  from 
the  operation  he  had  undergone.  During  the  first  three  days  the  boy 
passed  urine  freely,  but  with  some  dribbling.  He  had  slight  fever  every 
evening,  but  on  the  whole  was  daily  growing  stronger. 

On  December  30  I  found  the  lad  in  intense  pain,  with  stoppage  of  urine. 
On  passing  a  sound  I  found  that  the  stone  had  shifted  its  position,  and 


LITHOLAPAXY  IN  MALE  CHILDREN  AND  IN  FEMALES  89 

was  now  lying  in  the  bladder  right  up  against  its  neck ;  the  tumour  in  the 
groin  had  disappeared.  The  dislodging  of  the  stone  from  the  dilated 
ureter  was  due  no  doubt  partly  to  the  other  stone,  on  which  it  rested, 
having  been  removed,  and  partly  to  the  accumulation  of  urine  behind  it 
pushing  it  on  into  the  bladder.  Patient  at  once  anaesthetized,  and  htho- 
lapaxy  again  performed.  The  same  instruments  as  before  were  used,  and 
a  stone  of  nearly  the  same  size  removed.  The  operation  lasted  \\  hours, 
and  the  patient  was  much  exhausted. 

The  debris  (urates)  removed  at  the  first  sittuig  weighed,  when  dry, 
767  grains,  and  that  at  the  second  681  grains — total,  1,448  grains,  or  more 
than  3j  ounces.  For  the  first  three  or  four  days  the  lad  was  very  low, 
but  on  January  11  I  had  the  pleasm-e  of  shoTving  him  to  Surgeon-General 
W.  E.  Piice.  He  was  sittmg  up  in  bed,  quite  happy  ;  dribbling  of  urine 
had  ceased,  and  his  general  health  had  much  improved.  All  urinary 
symptoms  had  disappeared  on  January  20,  and  he  was  discharged  on 
January  22  in  fairly  good  general  health,  the  spleen  having  diminished 
much  in  size.     On  January  28  I  met  the  boy  walking  about  in  the  streets. 

It  is  in  such  cases  as  this  that  Bigelow's  operation  stands 
forth  in  brilhant  contrast  with  all  other  operations  for  stone, 
rescuing  from  certain  death  miserable  patients  on  whom  no 
cutting  operation  of  any  kind  could  be  undertaken  with  any 
hope  of  success. 

Females. — Amongst  864  operations  for  stone  in  the  bladder 
performed  by  me  there  were  17  in  females,  or  about  2  per 
cent,  of  the  whole.  Three  of  these  occurred  in  my  lithotomy 
days,  previous  to  my  commencing  litholapaxy.  These  three 
occurred  m  children,  and  the  calculi  were  removed  by  rapid 
dilatation  of  the  urethra.  Since  commencing  Bigelow's  opera- 
tion, 14  cases  of  stone  in  females  (7  children  and  7  adults) 
have  come  under  my  treatment,  and  of  these  13  have  been 
treated  by  litholapaxy  with  entire  success.  The  remainmg 
case  was  that  of  a  woman  aged  70.  I  attempted  litholapaxy, 
but  the  stone,  which  was  uric  and  weighed  exactly  two  ounces, 
was  so  extremely  hard  that,  though  it  was  easily  grasped  by 
my  largest  lithotrite,  No.  18,  I  could  make  no  impression  on 
it,  though  I  used  all  the  force  of  which  I  was  capable.  The 
stone  in  this  case  I  successfully  removed  by  vagmal  lithotomy. 


90  LITHOLAPAXY  IX  MALE  CHILDREX  AND  IN  FEMALES 

LitholapaxY  in  females  is,  as  a  rule,  not  a  difficult  j)i'o- 
ceeding,  the  instruments  employed  being  the  same  as  for 
males.  Even  quite  voung  female  children  admit  large  litho- 
trites  and  cannulse  without  any  preliminary  dilatation  of  the 
urethra.  The  only  special  difficulty  met  with  is  that,  owing 
to  the  width  and  shortness  of  the  urethral  canal,  the  water 
which  is  necessary  in  the  bladder  during  the  crushing  of  the 
stone  is  Uable  to  rush  out  beside  the  instruments.  This 
difficulty  is  obviated  by  getting  an  assistant  to  place  the  fore 
and  middle  j&ngers  of  one  hand  in  the  vagina,  and  to  press  the 
posterior  lip  of  the  urethra  against  the  lithotrite  or  cannula, 
a  manceu^Te  which  jDrevents  the  water  from  flowing  out. 
Litholapaxy  in  females  is  eminently  successful,  and  the 
patient  may  be  seen,  as  a  rule,  walking  about  the  day  after 
the  operation.  Xo  forcible  dilatation  of  the  urethra  being 
necessary,  there  is  no  incontinence  of  urine,  that  extremely 
troublesome  sequel  which  sometimes  follows  the  operation  by 
dilatation.  One  woman  from  whom  I  removed  a  calculus  over 
an  ounce  in  weight  was  seven  months  pregnant.  The  details 
of  this  interesting  case  are  as  follows : 

Case  390. — M.  C,  female,  aged  2.5,  admitted  to  Moradabad  Hospital, 
May  11,  1890,  with  symptoms  of  stone  of  one  year's  standing.  Seven 
months  gone  in  pregnancy.  Great  pain  in  the  region  of  the  bladder, 
which  becomes  so  intolerable  when  she  attempts  to  stand  or  walk  that  for 
three  months  she  has  had  to  keep  lying  down ;  this  evidently  due  to 
pressure  of  the  gravid  womb  on  the  bladder  with  contained  stone.  When 
she  desires  to  pass  urine,  she  has  to  insert  her  finger  in  the  urethra,  and 
push  back  the  stone  from  the  neck  of  the  bladder.  Next  day  I  performed 
litholapaxy.  The  stone  was  at  once  caught  by  my  No.  15  hthotrite, 
which  had  to  be  three  times  introduced  before  the  debris  was  completely 
extracted.  Cannula  No.  18  used.  No  flow  of  urine  beside  the  instru- 
ments, owing  to  the  precautions  above  indicated  having  been  adopted. 
The  calculus  was  mainly  urates,  and  weighed  477  gi'ains.  Time  spent  in 
operating,  seventeen  minutes.  Next  day  the  patient  was  sitting  up  and 
walking  about  her  room,  untroubled  by  any  vurinary  symptom.  She 
stated  that  she  was  quite  well,  and  desired  to  go  home.  Discharged  on 
17th  quite  well. 


LITHOLAPAXY  IN  MALE  CHILDREN  AND  IN  FEMALES  91 

This  is  a  very  interesting  case,  showing  that  the  operation 
may  be  undertaken  in  the  last  stages  of  pregnancy  without 
fear  of  causing  a  miscarriage.  I  hesitated  at  first  about 
undertaking  the  operation  till  after  the  woman's  confinement, 
but  her  miserable  condition,  and  the  fear  that  the  presence 
of  a  large  stone  in  the  bladder  would  greatly  interfere  with 
labour,  induced  me  to  operate  at  once. 


CHAPTEE  VII. 

INTERESTING  CASES,  WITH  PRACTICAL 
OBSERVATIONS. 

In  the  preceding  two  chapters  I  have  dealt  with  the  chief 
difficulties  and  complications  met  with  in  the  modern  opera- 
tion. I  will  now  give  some  interesting  cases,  with  practical 
remarks  thereon. 

Several  patients  of  eighty  years  and  over  had  large  calculi 
successfully  removed.  The  oldest  on  whom  I  have  operated 
was  a  Mahomedan,  aged  96,  from  whom  I  removed  successfully 
a  hard  uric-acid  calculus,  the  debris  of  which  weighed  9| 
drachms,  the  operation  lastmg  one  hour.  An  interesting 
feature  in  this  case  was  that,  till  about  a  month  before  coming 
under  observation,  the  patient  had  enjoyed  excellent  health, 
and  was  untroubled  by  any  urinary  symptoms.  The  details 
of  this  case  are  interesting,  so  I  give  them. 

Case  69. — This  was  a  case  in  private  practice.  The  patient,  a 
Mahomedan  of  Moradabad,  stated  that  he  was  close  on  100  years  of  age, 
and  by  calculation  he  appeared  to  be  96.  He  was  a  di'ied-up,  withered 
creature,  without  a  tooth  m  his  head,  consisting  almost  of  skin  and  bone. 
Several  of  his  sons  were  living,  and  one  of  them  looked  70  years  of  age. 
Till  about  a  month  before  coming  under  treatment  he  had  enjoyed  good 
health,  and  used  to  walk  about  daily.  He  was  suffering  from  weU- 
raarked  symptoms  of  stone,  especially  great  pain  m  passing  urine  ;  very 
weak,  and  tmable  to  leave  his  bed.  On  October  28,  1883,  I  performed 
litholapaxy,  the  debris  weighing  9^  drachms,  and  the  operation  lasting 
one  hour.  The  patient  raade  a  rapid  recovery,  and  was  able  to  walk 
about  on  November  13.     Five  months  afterwards  I  had  the  pleasure  of 


INTERESTING  CASES— PRACTICAL  OBSERVATIONS     93 

showing  this  old  gentleman  to  Surgeon-General  W.  Walker.  He  was 
then  in  excellent  health,  so  much  so  that  Dr.  Walker,  writing  of  him  at 
the  time,  amusingly  says  :  '  He  must  certainly  be  90,  and  looks  as  if  he 
might  hve  thirty  years  more,  and  then  do  service  as  an  old  rail !' 

The  rapidity  with  which  a  stone  may  be  removed  from  the 
bladder  by  the  modern  operation  will  vary  according  to 
circumstances.  The  crushing  power  of  the  lithotrite,  the 
efficiency  of  the  aspirator,  the  calibre  of  the  urethra,  the 
shape  and  capacity  of  the  bladder,  the  size  and  hardness  of 
the  stone,  the  dexterity  and  experience  of  the  operator,  are  all 
factors  that  will  have  to  be  taken  into  consideration.  The 
longest  time  I  have  spent  over  the  operation  at  one  sitting 
was  two  hours,  in  Case  517,  already  described,  during  which 
time  I  removed  6|  ounces  of  hard  stone. 

Given,  on  the  other  hand,  a  patient  with  a  capacious 
urethra  and  healthy  bladder,  the  rapidity  with  which  a  large 
stone  may  sometimes  be  removed  by  the  modern  instruments 
is  wonderful.     The  following  cases  well  illustrate  this  : 

Case  91. — -A.  male,  aged  35,  admitted  into  the  Bareilly  Hospital, 
June  21,  1884,  with  the  usual  symptoms  of  stone,  which  had  existed  two 
and  a  half  years,  the  pam  being  excessive  dui'ing  the  last  few  days  before 
admission.  It  was  necessary  to  incise  the  floor  of  the  urethra  slightly, 
and  then  my  largest  lithotrite  passed  with  ease.  Calculus  phosphatic, 
not  very  hard;  fragments  weighed  exactly  2  ounces.  The  operation 
lasted  only  seventeen  minutes,  only  two  introductions  of  the  instruments 
being  required.  Cannula  No.  18  was  used.  The  patient  recovered 
without  a  bad  symptom,  and  was  discharged  June  30. 

Case  562. — A  male,  aged  60,  admitted  to  Moradabad  Hospital, 
November  8,  1892,  with  stone  of  two  years'  duration.  Health  fair. 
Litholapaxy  performed.  No.  15  lithotrite  and  No.  16  cannula  introduced 
twice.  Calculus,  soft  phosphates  ;  weight  557  grains — nearly  1^  ounce. 
Time  occupied  by  the  operation  six  minutes.  Not  a  drop  of  blood  drawn. 
On  the  5th  the  patient  was  sitting  up,  quite  well,  and  discharged  on 
the  8th. 

Not  less  interesting  than  the  facility  with  which  large 
calculi  may  sometimes  be  removed  by  the  modern  operation 
is  the  rapidity  of  the  cure  that  ensues  in  some  cases,  even 


94    INTERESTING  CASES— PRACTICAL  OBSERVATIONS 

when  the  stone  is  large  and  the  operation  prolonged  over  a 
considerable  period.  This  has  been  well  illustrated  by  some 
of  the  cases  already  given.  I  will  give  details  of  two  other 
such  cases. 

Case  68. — A  male,  aged  55,  came  to  the  Moradabad  Hospital,  October 
20,  1883,  suffering  from  the  usual  sjTxiptoms  of  stone,  which  he  stated  had 
only  troubled  him  for  six  months,  dm-ing  which  time  he  had  great  diffi- 
culty in  passmg  water.  October  26  I  performed  htholapaxy,  Surgeon- 
General  C.  Plai;ck  being  present.  Calculus  very  tough  and  hard  to  crush  ; 
operation  lasted  thirty-four  minutes.  Stone  partly  oxalate  of  lime,  partly 
■uric  acid ;  debris  weighed  1  ounce  35  grains.  Catheter  No.  18  passed 
easily,  without  incising  the  meatus.  Next  day  the  patient  was  walking 
about  the  hospital  as  if  no  operation  had  been  performed.  On  October  30, 
the  day  on  which  the  man  was  discharged,  he  presented  himself  to  Dr. 
Plauck,  who  was  much  struck  with  the  rapidity  of  the  cure,  having  seen 
the  man  operated  on  four  days  before  only.  The  patient  was  in  high 
spirits,  and  gave  us  an  amusing  account  of  the  various  expedients  he  used 
to  have  recourse  to  in  order  to  pass  urine  before  the  operation.  He  said 
that  he  used  to  he  on  liis  back,  then  on  his  belly,  sometimes  on  one  side 
and  then  on  the  other,  but  frequently  without  avail.  When  these  positions 
failed  to  give  hun  rehef,  he  had  recourse  to  standing  on  his  head  with  his 
legs  in  the  air ;  but  even  then  he  frequently  could  not  pass  water. 

Case  80. — ^A  Mahomedan,  aged  45,  admitted  March  11,  1884,  with 
stone.  The  symptoms  had  existed  three  years.  Litholapaxy  performed 
by  me.  Surgeon  S.  Thomson  being  present.  The  operation  lasted  half  an 
horn-,  during  which  the  instruments  were  introduced  four  tunes.  The 
stone  was  a  hard  m'ic-acid  one,  and  the  debris  weighed  1  ounce  2^  drachms. 
The  patient  was  walking  about  the  hospital  next  day,  quite  well,  and 
desh-ous  of  going  home.  He  was  discharged  March  17,  having  had  no 
bad  sjTuptoms. 

In  practice  in  India  I  was  often  amused  by  the  naivete  of 
the  peasantry,  and  the  rude  devices  they  frequently  have 
recourse  to  for  the  relief  of  disease.  These  remarks  apply 
partly  to  Case  68,  above  recorded.  Of  a  somewhat  similar 
nature  was  Case  29,  in  which,  with  the  assistance  of  Dr.  Wilson, 
Ghurwal,  I  removed,  on  March  5,  1883,  a  calculus  weighing 
2^  drachms  from  a  hillman,  aged  46,  This  man  informed  us 
that  during  the  previous  year  he  had  been  in  the  habit  of 
employing  a  thin,  pliant  bamboo  twig,  which  he  produced,  to 


INTERESTING  CASES— PRACTICAL  OBSERVATIONS     95 

assist  him  in  passing  water.  This  he  passed  through  the 
urethra,  and  by  means  of  it  pushed  back  the  stone  from  the 
neek  of  the  bladder  prehminary  to  passing  urine.  He  now 
pulled  his  penis  with  force,  putting  it  on  the  stretch,  then 
relaxed  it,  when  some  urine  passed  away  with  a  rush.  This 
process  was  repeated  again  and  again  till  his  bladder  was 
emptied. 

I  have  already  stated  that  no  selection  of  cases  was  made, 
and  that  patients  in  the  very  worst  conditions  of  health  were 
frequently  operated  on.  This  will  have  been  apparent  from 
some  of  the  cases  already  given  in  detail.  In  order  to 
illustrate  what  the  modern  operation  is  capable  of  in  rescuing 
from  death  many  sufferers  on  whom  no  cutting  operation 
could  be  entertained,  I  am  tempted  to  give  details  of  the 
following  cases : 

Case  56. — A  Mahomedan,  aged  85,  was  brought  to  the  Moradabad 
Hospital,  August  8,  1883,  ^vith  symptoms  of  stone,  which  had  existed  five 
years.  Patient  extremely  exhausted  from  his  sufferings  ;  a  mere  skeleton, 
unable  to  walk  ;  carried  in  a  bed.  Pain  ia  the  bladder  very  severe  ; 
micturition  frequent,  only  a  few  di'ops  of  urine  comiag  away  at  a  time. 
No  albumen.  Patient  so  weak  that  no  operation  could  be  entertained  at 
once ;  kept  m  hospital  for  preparatory  treatment.  On  August  12  there 
was  scarcely  anj'  improvement ;  but,  as  the  man  was  clamouring  for  the 
operation,  Htholapaxy  was  performed.  Operatioii  lasted  nearly  an  hour  ; 
debris  of  calculus,  which  was  a  hard  uric-acid  one,  weighed  nearly 
If  ounces.  The  urethra  admitted  the  largest  hthotrite,  and  cannula 
No.  18.  "With  the  exception  of  slight  fever  for  the  first  day  or  two,  and 
some  pain  in  micturition,  there  was  not  a  bad  symptom.  On  the  18th  he 
was  walking  about  the  hospital,  and  expressed  himself  as  '  feelmg  forty 
years  yoimger  than  before  the  operation.'  This  man  was  discharged  on 
the  23rd  in  good  health.  Some  months  after,  when  out  in  the  Terai 
tiger  shootmg,  I  met  him  ui  his  native  village,  and  he  was  then  quite  well. 

Case  107. — G.  A.,  BareUly  City,  aged  45,  came  to  the  hospital,  suffering 
from  all  the  symptoms  of  stone,  which  had  existed  two  years.  The 
pinched  and  anxious  expression  of  his  face  indicated  that  he  had  undergone 
extreme  suffering.  He  was  pale,  thm,  and  anaemic ;  and  his  body  and 
limbs  consisted  almost  solely  of  skui  and  bone.  In  fact,  he  was  a  hviag 
skeleton.  The  man  was  unable  to  walk  from  pain  and  debUity,  and  had 
to  be  carried  in  a  bed.     My  assistant-surgeon  and  the  subordinates  of  the 


96    IXTERESTIXG  CASES— PRACTICAL  OBSERVATWXS 

hospital  considered  an  operation  unad^dsable,  as  the  patient  was  in  a  djing 
state.  ]\Iy  friend,  the  late  Surgeon-Major  J.  Corbett,  also  saw  the  casei 
and  agi-eed  with  me  in  thinMng  that,  were  hthotomy  the  only  alternative, 
it  would  be  ad^dsable  to  allow  the  man  to  die  unoperated  on,  as  he  would 
be  certain  to  sink  on  the  operating  table  from  shock  and  loss  of  blood. 
With  the  assistance  of  Dr.  Corbett,  I  performed  litholapaxy  September  24, 
removing  2  di-achms  of  hard  ui'ic-acid  calculus,  the  operation  lasting 
thh-ty-five  minutes.  With  the  exception  of  shght  fever  on  the  day  of  the 
operation,  the  patient  had  not  a  bad  symptom,  and  was  discharged 
October  4,  ten  days  after  the  operation,  in  good  health.  Subsequently,  he 
frequently  presented  himself  at  the  hospital  to  show  himself,  untroubled 
by  any  urinary  symptom. 

These  cases  are  merety  illustrative  of  many  of  a  similar  kind 
in  mv  practice.  In  neither  instance  could  lithotomy  be 
entertained,  as  the  patient  had  not  an  ounce  of  blood  to  spare. 
It  is  in  cases  of  this  kind  that  the  operation  of  litholapaxy 
stands  forth  in  brilliant  contrast  to  that  of  lithotomy,  and 
creates  a  marked  impression  by  the  rapidity  of  the  cure  and 
the  undisturbed  condition  of  the  parts. 

A  general  impression  once  prevailed,  which  finds  a  reflection 
in  the  present  day,  though  to  a  much  more  limited  extent,  to 
the  effect  that  the  Asiatic  is  a  better  subject  for  surgical 
operation  than  the  European.  This  impression  is  altogether 
erroneous,  and  contrary  to  my  experience  of  both  races.  And 
I  have  already  shown  from  large  statistics  that  the  mortality 
from  lithotomy  in  hospital  practice  in  India  was,  contrary  to 
the  prevalent  opinion,  the  same  as  in  England. 

There  is  also  an  impression  prevalent  to  the  effect  that 
natives  of  India  have  no  fear  of  the  surgical  knife.  In  fact, 
from  the  way  some  people  talk  and  write,  it  might  be  inferred 
that  a  native  submits  to  a  surgical  operation  as  a  kind  of 
harmless  diversion.  This  impression  is  altogether  erroneous. 
A  native  of  India  will  not,  as  a  rule,  submit  to  a  surgical 
operation  till  all  other  modes  of  treatment  fail,  and  he  is 
driven  to  it  through  extreme  pain,  mconvenience,  or  danger  to 
life.     And  it  is  for  this  reason  that  such  larQ-e  calculi  are  met 


INTERESTING  CASES— PRACTICAL  OBSERVATIONS     97 

with  in  that  country,  and  that  patients  suffering  from  cancer 
and  other  diseases  present  themselves  in  hospital  at  a  stage 
when  surgical  interference  is  useless. 

I  have  already  referred  to  the  varying  sensitiveness  of  the 
urethra  and  bladder  in  different  individuals,  the  passage  of 
instruments  in  some  instances  being  attended  by  considerable 
haemorrhage,  and  in  others  little  or  no  blood  being  lost.  The 
latter  class  is  well  illustrated  in  the  following  two  cases, 
which  present  some  additional  features  of  interest,  particularly 
that  of  changing  the  long  for  the  short  axis  of  the  stone,  when 
the  lithotrite  will  not  lock  on  it  in  the  former  position. 

Case  42. — A  male,  aged  45,  admitted  into  the  Moradabad  Hospital 
May  18,  1883,  with  symptoms  of  stone,  which  had  existed  eight  or  ten 
years.  Health,  fair;  trace  of  albumen  in  the  xirine.  Litholapaxy  per- 
formed. The  calculus  was  first  grasped  by  the  long  axis;  but,  the 
Hthotrite  not  lockmg  on  it,  this  was  changed  for  the  short  axis,  when  the 
instrument  locked.  The  stone,  extremely  hard  and  tough,  was  composed 
of  carbonate  of  lime,  with  an  oxalate  of  lime  nucleus.  The  operation  lasted 
one  hour  and  ten  mmutes,  several  introductions  of  the  instruments  being 
required.  The  debris  of  the  stone  weighed  2|  ounces.  The  stone  was  so 
difficult  to  crush  that  I  feared  it  would  be  necessary  to  postpone  the 
completion  of  the  operation  to  a  second  sitting ;  but,  by  perseverance,  I 
managed  to  get  away  all  the  debris.  Dm'ing  the  operation  there  was 
not  a  trace  of  blood  in  the  washings,  nor  was  there  any  bleeding  from 
the  urethral  mucous  membrane.  The  patient  recovered  without  a  bad 
symptom,  and  was  discharged  in  perfect  health,  May  29. 

Case  111. — A  male,  aged  55,  admitted  into  the  Bareilly  Hospital, 
October  25,  1884,  with  symptoms  of  stone,  which  had  existed  2|  years. 
On  the  26th  I  performed  litholapaxy,  Surgeons-Majors  Knox,  Barry,  and 
Corbett  being  present.  On  passmg  the  hthotrite,  the  stone  was  at  once 
grasped  by  the  long  diameter — 2f  inches — but  the  instrument  would  not 
lock.  The  long  axis  of  the  stone  was  then  changed  for  the  short,  when  the 
instrument  locked.  I  attempted  to  crush  the  stone,  but  three  times  failed 
to  do  so.  I  then  screwed  the  blades  together  with  all  the  force  I  was 
capable  of,  and  rested  a  second  or  two,  when,  suddenly,  the  stone  gave  way 
with  a  loud  report  that  was  audible  to  all  the  persons  in  the  room.  The 
fragments  were  then  disposed  of  with  comparative  ease.  The  calculus 
was  composed  of  uric  acid,  with  an  oxalate  of  lime  nucleus.  The  debris 
weighed  2  ounces  and  45  grains.  Catheter  No.  18  passed  with  ease. 
The   operation  lasted  only  twenty-six  minutes,  there   being   only  three 

7 


98    INTERESTING  CASES— PRACTICAL  OBSERVATIONS 

introductions  of  the  instruments.  No  haemorrhage — not  a  trace  in  the 
washings.  On  the  27th  the  patient  was  walking  about  the  hospital, 
passing  -urine  quite  clear,  and  without  pain.    Discharged  cured  November  5. 

The  loud  report  accompanying  the  crushing  of  the  stone  in 
Case  111  would  suggest  the  possibility  of  harm  accruing  to  the 
bladder  by  the  splintering  of  the  fragments  in  the  case  of 
large  stones  such  as  this.  In  this  case,  however,  the  recovery 
was  rapid  ;  and  that  no  injury  was  done  was  evident  from  the 
fact  that  there  was  no  bleeding  from  the  bladder  at  the  time, 
and  that  subsequently  no  bad  symptoms  supervened.  I  have 
frequently  verified  this  in  other  cases ;  but  it  is  well,  in 
dealing  with  large  and  hard  stones,  to  have  a  considerable 
quantity  of  water  in  the  bladder,  which  acts  as  a  kind  of 
buffer  between  the  fragments  and  its  walls.  Owing  to  the 
calculus  in  the  bladder  being  saturated  with  moisture,  the 
fragments  do  not  fly  with  force,  as  in  the  case  of  a  dry  stone. 

Amongst  my  cases  of  litholapaxy  a  remarkable  instance  of 
spontaneous  fracture  of  stone  in  the  bladder  occurred,  and, 
as  such  cases  are  extremely  rare,  perhaps  its  record  may  not 
be  out  of  place  here. 

Case  30.— A  male,  aged  35,  admitted  March  19,  1883,  with  the  usual 
symptoms  of  stone,  which  had  existed  1|  years.  Thhteen  days  previous  to 
admission  all  the  sj^mptoms  became  suddenly  aggravated,  since  which 
time  m-ine  had  only  been  passed  in  drops  with  difficulty.  On  placmg  the 
patient  on  the  table  with  a  view  to  passing  the  sound,  I  noticed  an 
elongated,  hard,  beaded  thickening  along  the  course  of  the  urethra,  and 
my  first  impression  was  that  there  was  a  severe  stricture  present.  Dr. 
Moran,  6th  Bengal  Infantry,  who  kindly  assisted  me  at  the  operation, 
remarked  that  the  feeling  was  like  that  of  urethral  calcuh.  The  floor  of 
the  meatus  was  incised,  and  no  less  than  1  drachm  of  calciilus  debris 
removed  by  the  urethral  forceps  and  scoop.  The  whole  length  of  the 
urethra  was  filled  with  pulverized  calculus.  A  sound  was  then  passed, 
and  fragments  detected  in  the  bladder.  The  lithotrite  was  introduced, 
and  litholapaxy  performed.  The  debris  removed  from  the  bladder, 
exclusive  of  60  grains  from  the  urethra,  weighed  125  grains.  On  inspec- 
tion of  the  fragments,  it  was  evident  that  they  belonged  to  one  phosphatic 
calculus.     The  patient  was  discharged  cured  March  27. 

The  following  case  illustrates  a  difficulty,  though  a  slight 


INTERESTING  CASES— PRACTICAL  OBSERVATIONS    99 

one,  which  I  have  only  once  met  with,  but  which  I  consider  of 
sufficient  interest  for  record  here  : 

Case  125. — S.  B.,  aged  45,  admitted  to  Mussoorie  Hospital,  September  6, 
1885,  suffering  from  the  usual  symptoms  of  stone,  wliicli  had  lasted  1h 
years.  On  passing  a  sound,  two  calculi  were  diagnosed.  On  the  7th  I  per- 
formed litholapaxy,  chloroform  being  given  by  Surgeon  Tyrrell,  and  Drs. 
Whittall,  Fiddes,  Murphy,  and  Burlton  being  also  present.  After  slitting 
the  floor  of  the  meatus,  the  large  lithotrite  passed  with  ease,  and  the 
calculi,  which  were  soft,  were  easily  crushed.  The  No.  18  cannula  passed 
with  facUity.  On  applying  the  aspirator  and  attempting  to  inject  water,  how- 
ever, the  apparatus  failed  to  work.  I  made  several  attempts  to  pump  m 
water,  but  to  no  effect.  I  then  withdrew  the  cannula,  and  found  that  it 
was  full  of  soft,  mortar-like  debris,  which,  when  removed  by  tapping  the 
cannula  against  a  vessel,  remained  in  the  form  of  a  cast  of  the  cannula,  like  a 
piece  of  thick  macaroni.  After  this  the  operation  proceeded  without  further 
difficulty,  and  the  patient  made  a  speedy  recovery.  In  fact,  he  was  sitting 
in  the  hospital  inclosure  next  day.  The  debris  consisted  mainly  of  phos- 
phates, and  weighed  41  drachms.  When  the  obstruction  to  the  ingress  of 
water  occurred,  I  was  at  a  loss  to  account  for  it,  and  first  imagined  there 
was  spasm  of  the  bladder,  such  as  is  sometimes  met  with  even  when  pro- 
found anaesthesia  exists ;  but  on  withdrawal  of  the  cannula  the  cause  was 
apparent.  The  debris,  being  in  a  plastic,  semi-fluid  state,  rushed  into 
the  cannula  immediately  it  was  introduced,  and  formed  a  cast  of  it. 

I  have  ah'eady  stated  that  for  that  form  of  cystitis  which 
exists  as  a  comphcation  of  stone  previous  to  operation,  no 
special  treatment  is,  as  a  rule,  necessary,  beyond  the  removal 
of  the  calculus — the  cause  of  the  disease.  That  form  of 
cystitis,  however,  which  so  often  followed  on  the  old  operation 
of  lithotrity,  and  which,  if  it  did  not  prove  fatal,  often  left 
the  patients  in  almost  as  bad  a  condition  as  they  were  in 
before  the  operation,  seldom  occurs  after  litholapaxy,  and 
when  it  does  occur  is  very  amenable  to  treatment. 

Should  cystitis  supervene  on  the  operation,  the  treatment 
during  the  acute  stage  will  consist  in  perfect  rest  in  bed,  the 
administration  of  alkalies  with  demulcent  drinks,  hot  baths, 
hot  fomentations  to  the  hypogastric  region,  poultices,  etc. 
The  local  treatment  that  I  have  found  most  effectual  in  the 
subacute  and  chronic  stages  of  cystitis  consists  in  the  injection 


loo  INTERESTING  CASES— PRACTICAL  OBSERVATIONS 


into  the  bladder  once  daily  of  a  weak  astringent  solution  of 
either  nitrate  of  silver  or  acetate  of  lead.  These  astringent 
solutions  are  best  applied  by  means  of  six-ounce  india-rubber 
bottles  (Figs.  36,  37),  provided  with  stopcocks,  the  nozzles  of 
which  fit  on  to,  or  inside  of,  the  end  of  a  No.  10  or  12  soft 
gum-elastic  catheter  provided  with  a  large  oval  eye.  The 
process  should  be  commenced  by  washing  out  the  bladder  with 


Fig.  36. 


Fig.  37. 


warm  water,  to  which  may  be  added  a  trace  of  carbolic  acid 
or  a  few  drops  of  a  solution  of  permanganate  of  potash.  When 
the  bladder  has  been  thus  cleansed  of  mucus,  pus,  and  shreds 
of  lymph,  the  astringent  is  applied.  The  astringent  solution 
should  at  first  be  very  mild,  say  ^  grain  of  either  of  the  salts 
above  mentioned  to  the  ounce,  and  may  be  gradually  increased 
in  strength,  no  pain  or  uneasiness  being  produced. 

These  remarks  do  not,  however,  apply  to  those  cases  of 
phosphatic  cystitis  sometimes  met  with  in  which  the  chronic 
disease  of  the  bladder  is  the  cause  of  the  formation  of  soft 
phosphatic  calculi,  not  the  result.     In  such  cases  the  removal 


INTERESTING  CASES— PRACTICAL  OBSERVATIONS   loi 

of  the  calculus  will  not  cure  the  disease.  But  the  habitual 
use  of  the  india-rubber  bottle  and  catheter  for  washing  out 
the  bladder  with  weak  astringents  will  alleviate  the  symptoms. 
For  this  form  of  chronic  cystitis,  with  a  tendency  to  deposit 
phosphates  on  the  mucous  membrane,  I  know  of  no  treatment 
so  effectual  as  a  judicious  course  of  the  waters  of  the 
Contrexeville  group ;  and  I  say  this  after  careful  study,  on 
the  spot,  of  the  results  obtained  at  Contrexeville  itself  and 
other  continental  spas  reputed  for  the  treatment  of  gravel 
and  stone,  and  many  years'  experience  of  the  administration 
of  these  waters  in  such  cases  in  my  own  practice.  These  waters 
dissolve  the  catarrhal  mucus  lining  the  urinary  passages, 
which,  with  the  entangled  phosphates,  is  carried  away  with 
the  copious  flow  of  urine  induced.  Ammoniacal  decom- 
position is  checked,  the  mucous  membrane  brought  into  a 
healthier  state,  and  the  acid  reaction  of  the  urine  restored. 


CHAPTER  VIII. 

SMALL  CALCULI:  THEIR  DIAGNOSIS  AND  REMOVAL. 
WHAT  IS  A  STONE  IN  THE  BLADDER  ? 

In  the  great  majority  of  cases  that  come  under  observation 
somiding  for  stone  is  a  simple  proceeding.  Almost  any  sound 
will  detect  a  large  or  even  moderate-sized  stone,  when  lying 
free  m  the  bladder.  The  form  of  sound  I  almost  invariably 
use  in  the  first  instance  is  one  of  the  shape  illustrated  in 
Fig.  28,  pro]3ortionate  to  the  age  of  the  patient.  A  sound  of 
this  shape  is  very  easy  to  mtroduce,  causing  the  patient  little 
or  no  pain  ;  and,  in  addition  to  detectmg  the  stone  as  a  rule, 
affords  collateral  information  regarding  the  capacity  of  the 
urethra.  Should  I  fail  to  detect  the  stone  by  this,  I  have 
recourse  to  a  sound  (Figs.  38,  39)  with  a  short,  well-curved 
beak  and  bulbous  end,  first  introduced  by  Mercier  of  Paris. 
The  short  beak  of  this  instrument  permits  of  its  rotation  in 
various  directions  in  the  bladder,  and  particularly  behmd  the 
prostrate  when  enlarged,  where  a  stone  frequently  lies  and 
may  be  passed  over  by  a  sound  with  a  long  beak.  Sir  Henry 
Thompson's  sound  (Fig.  40)  is  also  a  very  useful  one,  as,  being 
hollow,  by  the  removal  of  the  plug  at  the  end  of  the  handle, 
water  can  be  allowed  to  flow  from  the  bladder  without  with- 
drawmg  the  instrument,  and  the  \dscus  then  searched  with 
varying  quantities  of  fluid  in  its  interior. 

I  find,  however,  that  with  any  of  these   sounds  a  small 
calculus,  lying  in  some  peculiar  position  in  the  bladder,  may 


SMALL  CALCULL— THEIR  DLiGNOSIS  AXD  REMOVAL  103 


evade  detection  ;  and  experience  teaches  us  that  a  patient  is 
frequently  sent  away  from  hospital  with  a  stone  in  his  bladder 
when  an  opmion  to  the  contrary  has  been  expressed.  The 
detection  of  such  small  calculi,  before  they  grow  into  large 


Figs.  38,  39. 


rJ3  SCALE 
Fig.  40. 


ones,  is  of  vital  importance,  as  their  removal  by  the  modern 
method  is  a  very  simple  proceeding,  and,  as  a  rule,  unattended 
by  danger. 

In  the  Indian  Medical  Gazette,  March,  1884,  I  called  the 


I04  SMALL  CALCULI— THEIR  DIAGNOSIS  AND  REMOVAL 

attention  of  the  profession  to  a  new  method  of  diagnosis  f or 
small  calculi,  by  means  of  the  aspirator  and  cannula.  The 
method  of  employing  it  will  be  best  indicated  by  a  case  from 
actual  practice. 

Case  54. — On  August  1,  1883,  a  male,  aged  50,  came  to  hospital  with 
symptoms  of  stone,  the  most  marked  of  which  were  sudden  stoppage  of 
urine  and  increased  frequency  of  micturition.  After  a  most  careful 
exploration  of  the  bladder  by  sounds  of  various  kinds,  including  Sir 
Henry  Thompson's,  no  calculus  could  be  detected.  I  felt  certain,  how- 
ever, from  the  sj-mptoms,  that  there  was  a  small  stone  present,  and 
determined  to  employ  Bigelow's  asphator  for  the  purpose  of  diagnosis. 
I  introduced  a  No.  14  cannula  and  apphed  the  aspirator.  After  going 
through  the  performance  of  pumping  water  into  the  bladder  and  ex- 
hausting it  once  or  twice,  a  distmct  click  was  heard.  The  cannula  was 
withdrawn,  the  lithotrite  introduced,  and  the  stone  crushed.  The 
fragments  weighed  11  grains  only.  Next  day  the  man  was  walking 
about  quite  well. 

In  the  above  case  a  most  careful  search  was  made  by 
sounds  of  various  kinds,  but  no  calculus  could  be  detected 
till  the  aspirator  was  employed,  when  a  distinct  click  was 
heard  during  the  exhaustion  of  the  water,  due  to  the  calculus 
being  carried  with  force  against  the  eye  of  the  cannula  by  the 
outward  stream.  The  sound  of  the  fragments  clicking  against 
the  cannula  durmg  aspiration  in  the  operation  of  litholapaxy 
first  suggested  to  me  this  mode  of  diagnosis,  and  I  now  always 
employ  it  when  the  symptoms  of  stone  are  present,  and  the 
sound  fails  to  detect  one.  In  this  way  I  have  detected  many 
small  calculi. 

The  practical  advantages  of  this  simple  mode  of  diagnosis 
for  small  calculi  are  borne  testimony  to  by  several  of  my 
fellow-labourers  in  this  department  of  surgery,  especially  by 
Keegan  and  Harrison ;  and  I  find  that  it  is  now  very  generally 
employed.  Harrison  remarks*  that  '  where  the  bladder  has 
lost  its  shape,  either  by  the  encroachment  of  the  prostate  or 

*  '  Further  Observations  on  the  Treatment  of  Stone  in  the  Bladder,'  by 
E.  Harrison,  F.E.C.S.,  1885,  p.  2. 


SMALL  CALCULI— THEIR  DIAGNOSIS  AND  REMOVAL    105 

by  the  development  of  saccules,  the  detection  of  a  small 
calculus  is  often  attended  with  considerable  difficulty,  and 
may  be  doubtful.'  In  cases  of  this  nature,  and  others  '  where 
stone  is  suspected,  but  cannot  be  readily  detected  on  the 
introduction  of  a  sound,'  Harrison  says  that  he  has,  since 
reading  my  paper  in  the  Indian  Medical  Gazette,  systematically 
employed  my  method  of  diagnosis  ;  and  adds :  '  I  have  by 
this  instrument  (the  aspirator-cannula)  been  enabled  in  at 
least  a  dozen  instances,  not  only  to  detect  the  stone  without 
distressing  the  patient,  but  at  once  to  remove  it.' 
A  typical  example  is  given  by  Mr.  Harrison  : 

'  In  a  recent  case  of  irritable  bladder  with  cystitis,  which  I  saw  in 
consultation  with  Mr.  Eichard  Wilhanis,  where  we  had  reason  to  suspect 
stone  in  the  bladder,  the  process  was  adopted,  and  may  well  serve  as  an 
illustration.  We  first  carefully  examined  the  bladder,  under  ether,  with 
a  sound,  but  failed  to  detect  a  stone  in  consequence  of  the  great  irregularity 
in  the  shape  of  the  mferior  portion  of  the  viscus.  The  aspirator-catheter 
was  substituted  for  the  sound,  when  calculi  were  at  once  found  clicking 
against  the  eye  of  the  instrument.  In  this  way,  not  only  was  the 
presence  of  stone  demonstrated,  but  these  were  readily  removed,  when  we 
were  able  to  declare  that  the  viscus  was  free.' 

And  he  adds :  '  By  this  simple  process  the  operation  of 
sounding  has  been  rendered  more  certain,  and  freer  from 
those  consequences  which  are  sometimes  inseparable  from 
the  more  usual  method  when  required  in  the  case  of  abnor- 
mally shaped  bladder.' 

Not  alone  may  the  aspirator  be  usefully  employed  for 
diagnostic  purposes,  but  by  means  of  it  a  small  calculus, 
or  number  of  small  calculi,  may  be  removed  entire,  without 
the  necessity  of  having  recourse  to  the  lithotrite  at  all. 
Case  76  is  a  practical  illustration  of  this. 

Case  76. — A  warder  in  the  Moradabad  gaol,  aged  50,  had  been  passing 
gravel  for  two  or  three  years,  when  suddenly,  on  December  17,  1884,  his 
urine  ceased  to  flow.  He  went  to  the  hospital  assistant,  who  passed  a 
catheter  and  reheved  the  retention.  Next  day  he  had  retention  again, 
when  he  consulted  me  at  my  morning  visit  to  the  gaol.     I  sent  him  to 


io6  SMALL  CALCULL—THEIR  DIAGNOSIS  AND  REMOVAL 

the  Civil  Hospital,  placed  him  under  the  influence  of  chloroform,  and 
passed  a  No.  18  cannula.  The  aspirator  was  then  applied,  and  the  click 
of  a  stone  heard.  The  calculus,  which  weighed  only  15  grains,  passed 
into  the  apparatus,  and  was  removed  in  this  way,  without  the  use  of  the 
lithotrite.  Next  daj^  the  warder  retui-ned  to  his  work  quite  well,  having 
suffered  no  unpleasant  sj-mptoms. 

I  had  for  some  time  previously  contemplated  the  removal 
of  a  small  calculus  in  this  way  by  the  aspirator  alone,  but 
this  was  the  first  opportunity  I  had  of  putting  my  idea  to  a 
practical  test.  Since  then  I  have  removed  calculi  in  several 
instances  in  this  manner  without  the  aid  of  the  lithotrite. 

When,  however,  the  stone  is  fixed  in  position  in  the  bladder, 
whether  in  a  narrow-mouthed  sac,  wedged  in  between  the 
prostate  and  the  wall  of  the  bladder,  or  held  in  position  by 
rugose  folds  of  the  mucous  membrane  and  tenacious  mucus, 
even  this  method  of  diagnosis  may  fail.  It  is  in  cases  of  this 
kind  that  electric  illumination  of  the  bladder,  which  has  done 
so  much  towards  the  diagnosis  and  elucidation  of  the  nature 
of  tumours  of  that  viscus,  is  peculiarly  adapted.  This  is  not 
the  place  to  enter  on  a  description  of  the  method  of  employing 
Leiter's  electric  cystoscope  (Fig.  41).  Full  details  will  be 
found  in  Fen  wick's  excellent  work,  '  The  Electric  Illumma- 
tion  of  the  Bladder  and  Urethra,' 

The  reader  may  remember  the  controversy  that  took  place 
some  time  back  mthe  columns  of  the  British  Medical  Joui-nal* 
between  Sir  Henry  Thompson  and  myself  with  reference  to 
the  question,  '  What  is  a  Stone  in  the  Bladder  ?'  In  that 
correspondence  Sir  Henry  attempted  to  lay  down  certain 
novel,  but  somewhat  arbitrary,  rules,  which,  if  adopted,  would 
have  had  the  effect  of  removmg  these  small  calculi  altogether 
from  the  category  of  stone  in  the  bladder.  In  the  British 
Medical  Journal  of  December  27,  1887,  I  had  published  a 
paper  on  'A  Eecent  Series  of  One  Hundred  Operations  for  Stone 
in  the  Bladder  without  a  Death,'  amongst  which  there  were  a 
*  February  18,  July  7,  July  14,  1888. 


SMALL  CALCULI— THEIR  DIAGNOSIS  AND  REMOVAL  107 

few  very  small  calculi,  some  of  them  in  children.  Taking 
this  paper  as  his  text,  Sir  Henry  formulated  certain  proposals 
for  the  acceptance  of  the  profession,  which,  in  his  own  words, 
are  as  follows : 

(1)  '  Any  calculus  which  can  be  by  any  means  removed  entire  through 


Fig.  41. 


the  urethra,  including  one  impacted  therein  and  removed  thence  by  the 
knife,  cannot  be  admitted  to  rank  as  a  vesical  stone,  nor  can  such  an 
operation  be  regarded  as  one  for  stone  in  the  bladder.' 

(2)  '  That,  for  those  which  are  crushed,  only  formations  of  a  certain 
weight  (20  grains  and  upwards)  can  be  fairly  described  by  the  word  stone.' 


io8  SMALL  CALCULI— THEIR  DIAGNOSIS  AND  REMOVAL 

Why  Sir  Henry  Thompson  should  have  thought  it  necessary 
to  formulate  the  self-evident  truth  contained  in  the  first  of 
these  propositions  I  am  at  a  loss  to  understand,  for  who  ever 
heard  of  a  urethral  calculus  being  regarded  as  a  stone  in  the 
bladder,  whether  removed  by  the  knife  or  otherwise  ! 

As  the  second  of  these  propositions  seemed  to  me  un- 
scientific, unpractical,  and  at  variance  with  those  prmciples 
which  Sir  Henry  himself  had  laid  down  for  his  own  guidance 
during  the  most  active  part  of  his  career,  I  ventured  to 
question  the  propriety  of  any  such  change  of  nomenclature 
on  the  following  grounds  : 

(1)  I  need  scarcely  say  that  from  time  immemorial  the 
universally  accepted  definition  of  stone  in  the  bladder  had 
been  :  Any  calculous  formation,  no  matter  of  what  size,  which 
failed  to  pass  out  of  the  bladder  spontaneously,  and  for  the 
removal  of  which  an  operation  was  necessary. 

(2)  Sir  Henry  Thompson's  views  on  this  self-same  question 
had,  a  short  time  previously,  been  clearly  set  forth  in  his 
'Lectures,'  delivered  at  the  College  of  Surgeons  in  1884.  '  I 
think,'  he  therein  wrote,  '  it  will  be  generally  agreed  that 
when  a  bladder  is  found  for  the  first  time  to  contain  a  calculus, 
whether  urate,  oxalate,  or  phosphate,  which  is  too  large  to  be 
expelled  by  the  natural  efforts,  the  crushing  and  removal  of  it 
(together  with  others,  if  such  be  present),  so  as  to  empty  the 
bladder,  necessarily  constitutes  an  "operation  for  the  stone," 
whether  it  or  they  be  large  or  small.  If  a  small  stone  only  is 
present,  the  patient  is  fortunate  in  having  it  detected,  because 
it  would  inevitably  have  become  large  had  it  not  been  dis- 
covered, and  the  operation  is  then  attended  with  a  corre- 
sponding increase  of  risk.' 

These,  indeed,  are  words  of  wisdom,  and  I  submit  there 
could  be  no  stronger  condemnation  of  the  position  assumed 
by  Sir  Henry  in  1888,  in  criticising  my  work,  and  of  his 
attempt  to  eliminate  from  the  category  of  stone  in  the  bladder 


SMALL  CALCULI— THEIR  DIAGNOSIS  AND  REMOVAL  109 

calculi  of  20  grains  and  under,  than  these  words  quoted  from 
his  writings  in  1884  with  reference  to  his  own  work. 

It  is  to  be  presumed  that  the  principles  here  so  clearly 
enunciated  were  those  by  which  Sir  Henry  was  guided  in  his 
practice,  and  that,  if  he  had  no  calculi  below  20  grains  in 
weight  in  his  collection,  this  was  due  to  the  fact  that  he  had 
not  met  with  such,  or  had  failed  to  detect  them  by  the 
methods  of  diagnosis  employed  by  him.  The  fact  is,  the 
diagnosis  of  small  calculi  of  this  kind  was  extremely  difficult 
before  the  introduction  of  my  method  of  diagnosis  by  the 
cannula  and  aspirator,  already  described,  and,  more  recently, 
of  the  electric  illumination  of  the  bladder  by  Leiter's  cysto- 
scope,  so  that  this  fact  may  to  some  extent  account  for  their 
absence  from  Sh'  Henry's  collection. 

(3)  It  is  a  well-known  fact  that  these  small  calculi  are 
frequently  attended  by  symptoms  of  the  most  painful  and 
dangerous  character,  not  the  least  being  their  liability  to  pass 
into  the  prostatic  urethra  and  cause  retention  of  urine.  If 
not  removed  when  small,  they  grow  into  large  stones,  and  it 
is  one  of  the  greatest  triumphs  of  Bigelow's  operation,  and  its 
development  in  my  hands,  that  calculi  which  before  baffled 
detection  can  now  be  diagnosed  and  removed  with  facility. 

(4)  Though,  as  a  rule,  these  small  calculi  can  be  removed 
with  absolute  safety,  experience  has  taught  me  that  the 
modern  operation  in  such  cases  is  not  altogether  devoid  of 
danger,  even  in  the  adult,  as  the  following  case  will  show  : 

Case  274. — A  male,  aged  32,  admitted  to  the  Colvin  Hospital,  Allahabad, 
October  4,  1888,  with  retention  of  urine,  due  to  stone  unpacted  in  the 
prostatic  urethra.  Bladder  enormously  distended ;  man  in  fearful  agony. 
EeHeved  by  catheter  by  my  assistant  surgeon,  the  calculus  passing  back- 
wards into  the  bladder.  Next  day  I  performed  Htholapaxy,  Surgeon- 
Captain  Irwin  being  present.  The  calculus  was  easily  caught  and 
crushed,  and  the  debris  (weight,  5  grains)  removed  through  a  Ko.  14 
cannula,  the  operation  lasting  five  minutes.  Dtning  the  night  the  patient 
had  high  fever,  temperature  106°  F.,  and  was  wildly  delirious.  On  the 
6th  the  fever  was  less,  but  the  pulse  was  extremely  weak  and  rapid,  with 


no  SMALL  CALCULI— THEIR  DIAGNOSIS  AND  REMOVAL 

cold,  clammy  perspiration,  so  that  we  feared  the  patient  was  dying, 
Torme,  however,  passing  freely.  On  the  8th  the  fever  had  gone,  and  by 
the  12th  the  patient  was  quite  well. 

Had  this  patient  died,  it  would  be  necessary,  in  accordance 
with  Sir  Henry  Thompson's  proposal,  to  omit  the  case  from 
the  list  of  deaths  following  the  operation  of  litholapaxy ! 
Edmund  Owen,  in  the  Lettsomian  Lectures,  1890,  whilst 
completely  accepting  my  views  in  this  controversy,  in  calling 
attention  to  this  aspect  of  the  case,  amusingly  emphasized  the 
absurdity  of  Sir  Henry  Thompson's  proposal. 

(5)  Sir  Henry  did  not  question  the  right  of  these  small 
calculi  to  be  regarded  as  '  stone  in  the  bladder '  when  a  cutting 
operation  is  employed  for  their  removal.  Shortly  after  Sir 
Henry's  first  paper  came  to  hand,  two  cases  occurred  m  my 
practice  which  presented  a  timely  satire  on  this  new  departure 
in  nomenclature.  On  March  9,  1888,  I  removed  by  litholapaxy 
from  the  bladder  of  a  male  child,  aged  9  years,  a  calculus 
weighing  6  grains,  the  symptoms  having  existed  two  years. 
On  the  16th  of  the  same  month  I  removed  by  lithotomy  from 
a  male  child,  aged  2|  years,  a  calculus  weighing  4  grains,  the 
symptoms  having  existed  two  months.  Both  patients  did 
well.  According  to  Sir  Henry  Thompson,  the  latter  is  to  be 
regarded  as  a  stone  in  the  bladder,  but  not  the  former !  How 
then,  I  would  ask,  are  the  results  of  the  two  operations  to  be 
compared?  I  find  that  amongst  my  254  lithotomies,  there 
were  34  calculi  less  than  20  grains  in  weight ;  and  amongst 
my  610  litholapaxies,  88  calculi  of  this  size,  nearly  half  of 
them  in  children.  Sir  Henry  Thompson's  proposal  would 
involve  my  scoring  out  the  latter,  whilst  retaining  the  former 
on  my  list  of  operations  for  stone  in  the  bladder — a  proposition 
as  unscientific  as  it  is  absurd. 

It  was  with  great  diffidence  that  I  had  to  take  exception  to 
Sir  Henry  Thompson's  manner  of  dealing  with  the  statistics 
of  my  work,  and  particularly  to  some  false  impressions  left 


SMALL  CALCULI— THEIR  DIAGNOSIS  AND  REMOVAL    in 

behind  by  the  perusal  of  his  paper.  I  should  not  consider  it 
necessary  to  refer  to  the  matter  again,  were  it  not  that  I 
observe  that,  in  a  work  *  recently  published  by  Sir  Henry,  he 
again  returns  to  the  charge,  omitting,  however,  any  allusion 
to  my  reply  thereto. 

One  of  the  impressions  left  behind  was,  that  any  success 
that  I  had  attained  in  this  branch  of  surgery  was  due  to  my 
dealing  mainly  with  small  calculi.  The  pages  of  this  work 
will  have  shown  how  utterly  groundless  was  this  impression, 
and  that  if  I  have  pushed  Bigelow's  operation  in  the  direction 
of  small  calculi,  I  have  not  refrained  from  grappling  with 
those  of  very  large  size. 

I  think  that  it  will  be  generally  agreed  that  after  we  reach 
a  certain  size  of  stone — say  one  drachm — the  difficulty  of 
dealing  with,  and  the  danger  attaching  to  the  removal  of,  a 
stone  will  increase  directly  with  its  size ;  and  that,  taking  the 
small  with  the  large,  the  avercu/e  weight  of  calculi  removed  by 
any  particular  surgeon  will  give  the  best  indication  of  the 
difficulty  of  the  cases  dealt  with.  Considering  the  marked 
manner  in  which  Sir  Henry  Thompson  calls  attention  to  the 
cases  of  small  calculi  removed  by  me,  and  the  importance  he 
seems  to  give  to  his  having  no  calculi  below  20  grains  in  his 
list,  it  might  be  reasonably  anticipated  that  he  is  in  the  habit 
of  dealing  with  larger  stones  than  I  am ;  and  that  the  average 
weight  of  his  calculi  would  show  a  large  excess  over  that  of 
mine.  But  what  are  the  facts  of  the  case  ?  I  refer  the  reader 
to  the  very  able  monograph  on  Lithotrity,  in  Heath's  Dictionary 
of  Surgery,  written  by  Mr.  Cadge,  of  Norwich,  in  which  he 
points  out  that  the  average  weight  of  stone  in  my  first  108  cases 
of  litholapaxy  was  317  grains  (nearly  f  of  an  ounce),  whereas 
the  average  weight  in  Sir  Henry  Thompson's  75  cases  done 
by  Bigelow's  method  was  130  grains  (a  little  over  |  of  an 
ounce).  That  is  to  say,  the  average  weight  of  my  calculi  was 
nearly  two  and  a  half  times  larger  than  that  of  Sir  Henry 
*  Introduction  to  '  Catalogue  of  Calculi,'  1894. 


112  SMALL  CALCULL— THEIR  DIAGNOSIS  AND  REMOVAL 

Thompson's.  These  facts  dispose  of  the  erroneous  impression 
I  have  referred  to. 

From  the  vague  and  mdefinite  way  in  which,  \Yhilst  dealing 
^Yith  my  cases,  Sir  Henry  wrote  about  the  possibihty  of  his 
increasing  the  number  of  his  operations  by  recording  all  his 
cases  of  recurrent  stone,  the  impression  was  conveyed  that  I 
had  utilized  this  method  of  augmenting  my  operations.  As  I 
have  already  pointed  out  in  Chapter  IV.,  my  610  litholapaxies 
occurred  in  599  different  individuals — there  being  only  11 
recurrent  operations.  And  I  may  add  that  my  864  operations 
for  stone,  by  all  methods,  occurred  m  849  different  individuals, 
giving  15  recurrent  operations  in  all.  From  Sh-  Henry's  recent 
work  already  referred  to  (p.  23),  I  find  that  his  1,007  opera- 
tions for  stone  by  all  methods  occurred  in  887  individuals, 
giving  no  less  than  120  recurrent  operations ! 

On  further  examination  of  these  statistics,  I  find  the  re- 
markable fact  brought  out  that  these  recurrences  all  took 
place  amongst  Sh  Henry's  lithotrity  patients.  Thus,  there 
were  850  lithotrities  on  730  individuals,  giving  over  16  per 
cent,  of  recurrences ;  and  155  lithotomies,  besides  2  extractions 
by  dilatation  of  the  urethra  in  females,  in  157  persons.  Amongst 
these  latter  157  operations  by  lithotomy  in  patients  of  all  ages 
there  were  49  deaths,  or  31*21  per  cent.  Allowmg  for  this 
very  high  mortality,  there  remamed  108  patients  in  whom  no 
recurrence  of  stone  took  place.  How  does  it  happen  that  in 
Sir  Henrj^'s  practice  there  were  no  recurrences  amongst  his 
lithotomy  cases,  whilst  he  has  had  such  a  large  percentage  of 
recurrent  stones  amongst  his  lithotrity  operations  ?  This  fact 
Sir  Henry  does  not  explain ;  but  one  is  irresistibly  driven  to 
the  conclusion  that  it  was  due  to  something  inherent  in  the 
operation ;  and  that  these  frequent  recurrences  after  his  litho- 
trities were  in  large  part  due  to  a  diseased  state  of  the  bladder 
remaining  after  the  operation,  which  favoured  the  formation  of 
phosphatic  stones,  or  to  fragments  left  behind,  which  formed 
the  nuclei  of  fresh  calculi. 


CHAPTER  IX. 

CONCLUDING  REMARKS. 

To  sum  up,  then,  it  will  be  observed  that  litholapaxy  is  the 
operation  advocated,  as  a  rule,  m  patients  of  all  ages  and  both 
sexes  suffering  from  stone  in  the  bladder.  There  must, 
however,  always  remain  a  small  number  of  cases  in  which  this 
operation  will  be  inapplicable.  Such  cases  are  :  (1)  When 
the  stone  is  extremely  large  and  hard ;  (2)  some  cases  of 
encysted  calculi,  particularly  when  the  sac  is  narrow-mouthed ; 
(3)  calculi  partially  impacted  in  the  prostatic  urethra,  which 
cannot  be  displaced  backwards  into  the  bladder  ;  (4)  when  the 
stone  co-exists  with  tumour  of  the  bladder,  and  it  is  desirable 
to  empty  the  viscus  of  both  growths  at  one  operation ; 
(5)  where  there  is  great  enlargement  of  the  prostate  ;  (6)  when 
tight  cartilaginous  stricture  of  the  urethra  complicates  the 
case ;  and  (7)  when  the  bladder  is  contracted,  rigid  and 
irritable,  resenting  the  presence  of  water,  and  not  allowing 
room  for  the  manipulation  of  lithotrites.  In  such  cases 
lithotomy  of  some  kind  must  still  be  had  recourse  to  ;  and  the 
kind  of  lithotomy — whether  lateral,  median,  or  suprapubic — 
will  depend  on  the  circumstances  of  the  particular  case.  As 
the  surgeon  gains  experience  of  the  modern  operation,  the 
number  of  cases  in  which  the  use  of  the  knife  will  be 
necessary  will  gradually  diminish.  As  I  have  already 
mentioned,  there  were  amongst  my  last  300  cases  of  stone 
only  6  lithotomies,  litholapaxy  having  been  found  feasible  in 

8 


1 1 4  CONCL  UDING  RE  MA  RKS 

all  the  others.  Several  of  the  cases  of  stone,  even  m  the  adult, 
treated  by  me  by  lithotomy  after  I  began  to  practise  litholapaxy 
I  would  now,  with  my  present  experience,  treat  by  the  latter 
operation. 

The  old  operation  of  lithotrity,  as  practised  by  Civiale 
and  Thompson,  may  now  be  regarded  as  dead  and  buried. 
Under  no  circumstances  can  I  conceive  its  practice  justifiable  ; 
that  is  to  say,  with  modern  appliances  at  hand,  under  no 
chxumstances  should  a  stone  be  crushed  and  its  fragments 
allowed  to  remam  in  the  bladder  to  come  away  by  natural  efforts. 

In  an  article  in  the  Lancet  published  in  1885,  already 
referred  to,  I  ventured  to  appeal  to  the  profession  that 
Bigelow's  operation  should  be  universally  recognised  to  be, 
what  it  undoubtedly  was,  a  distinctly  new  operation.  This 
appeal  was  necessary  owmg  solely  to  the  attitude  of  Sir  Henry 
Thompson  in  regard  to  the  operation.  Shortly  after  the 
introduction  of  litholapaxy,  Sir  Henry  assumed  a  position  of 
opposition  to  this  view.  In  a  lecture  delivered  at  University 
College  Hospital  in  December,  1878,*  an  attempt  was  made  by 
him  to  show  that  the  new  operation  had  been  gradually 
developed  out  of  the  old  operation  of  lithotrity,  the  previous 
existence  of  Clover's  syringe,  and  the  assertion  that  Sh'  Henry 
himself  had,  during  the  previous  two  years,  been  in  the  habit 
of  doing  more  at  each  sitting,  both  in  the  way  of  crushing  and 
removal  of  fragments,  than  formerly,  being  mainly  relied  on 
as  the  connecting  links  in  establishing  their  identity. 
Bigelow's  share  in  the  development  of  the  operation  was 
minimized ;  his  instruments  were  denounced  as  incapable  of 
performing  the  work  assigned  to  them,  and  held  up  to  ridicule 
as  '  enormous  and  unwieldy,' — suggestmg  to  Sir  Henry's 
mind  '  some  resuscitated  relics  of  the  early  history  of 
lithotrity,'  reminding  him  of  'the  terrible  engines  used  by 
Heurtelop,' — and  disastrous  results  were  anticipated  from  the 
*  Lancet,  vol.  i.,  1879,  p.  145. 


CONCLUDING  REMARKS  115 

alleged  proposal  of  Bigelow,  '  to  make  the  rule  absolute  to 
remove  at  one  sitting  an  entire  stone,  no  matter  how  large  it 
may  be  or  what  the  condition  of  the  patient,'  a  proposal  which 
would  seem  to  have  had  its  origin  in  the  imagination  of  the 
lecturer,  for  Bigelow  asserts  that  no  such  proposal  had  ever 
been  made  by  him.  Eead  by  the  light  of  many  years' 
practical  experience  of  the  operation  all  over  the  world,  the 
gloomy  anticipations  then  expressed  do  not  appear  to  have 
been  realized.  Sir  Henry  seems  to  have  altered  his  opinions 
very  materially  since  that  time,  for  we  find  from  his  most 
recent  writings  that  lithotrites  and  evacuating  catheters, 
which  were  then  pronounced  dangerous  and  unnecessary,  are 
now  held  to  be  admissible,  and  even  necessary,  when  dealing 
with  large  calculi. 

It  is  rather  strange  that  Sir  Henry  Thompson  should  claim 
for  Clover's  syringe  an  efficiency  as  an  aspirator  which  in  its 
original  and  unmodified  form  it  never  possessed.  The 
apparatus  is  referred  to  by  most  authors  as  a  pretty  and 
ingenious  one  for  washing  out  the  bladder.  Its  use  in 
lithotrity  is,  however,  deprecated,  save  in  exceptional  cases, 
such  as  where  enlargement  of  the  prostate  or  atony  of  the 
bladder  co-exists  ;  and  then  the  only  efficiency  claimed  for  it 
is  that  of  washing  out  sand.  Thus  Mr.  Cadge,  of  Norwich, 
writes  :*  'In  doing  this  [removing  calculi  under  the  circum- 
stances above  referred  to]  I  have  sometimes  used  Clover's 
syringe,  but  more  frequently  have  trusted  to  the  quicker  and 
less  disturbing  action  of  the  scoop  lithotrite.'  In  1869  Sir 
Henry  Thompson,  writing  of  the  removal  of  fragments  by 
Clover's  syringe,!  says:  'The  process  is  rather  trying, 
however,  for  the  bladder  ;  and  it  costs  rather  more  pain  and 
time  than  an  ordinary  sitting  for  lithotrity.'  Again,  in  1871? 
he   writes : J  'Having    used    it     [Clover's    apparatus]     very 

*  Lancet,  vol.  i.,  1879,  p.  471.  , 

f  '  Diseases  of  the  Urinary  Organs,'  p.  125. 

X  '  Practical  Lithotrity  and  Lithotomy,'  p.  215. 


ii6  CONCLUDING  REMARKS 

frequently,  I  would  add  that  it  is  necessary  to  use  all  such 
apparatus  with  extreme  gentleness,  and  I  prefer  to  do  without  it 
if  possible.'  And  that,  even  so  late  as  1878,  Sir  Henry  relied 
much  more  on  the  fiat-bladed  lithotrite  for  the  evacuation  of 
the  debris  (Fergusson's  method)  than  on  Clover's  syringe,  is 
apparent  from  a  passage  in  the  lecture  delivered  by  him  m 
December,  1878,  already  referred  to. 

Bigelow  applied  the  name  '  litholapaxy '  to  his  operation  ; 
bat  to  this  Sir  Henry  Thompson  objects,  suggesting  '  lithotrity 
at  one  sitting '  as  more  appropriate.  Now,  I  think  there  are 
many  advantages  in  having  a  distinctly  new  name  for  a 
distinctly  new  departure  in  surgery.  The  word  litholapaxy 
(Xt^o9,  a  stone,  and  XaTraft?,  evacuation)  seems  to  me  the  one 
most  expressive  of  the  procedure  involved  in  the  new  opera- 
tion. Bigelow's  operation  involves  much  more  than  the 
crushing  of  the  stone,  the  essential  feature  being  its  complete 
and  rapid  evacuation.  Besides,  as  I  have  already  pointed  out, 
there  are  many  cases  in  which  a  small  calculus  can  be 
removed  by  the  aspirator  alone,  in  which  no  crushing  is 
required,  and  to  which,  consequently,  the  name  '  lithotrity  at 
one  sitting '  cannot  be  applied,  whereas  the  word  *  litholapaxy  ' 
will  also  embrace  these. 

There  can  be  no  doubt  whatever  that  Bigelow's  operation 
was  a  distinct  innovation  both  as  regards  the  principles 
involved  and  the  means  by  which  it  was  accomplished.  The 
operation  struck  at  the  root  of  all  previously  held  tenets 
regarding  lithotrity ;  and  its  introduction  caused  at  the  time 
astonishment  to  the  profession  all  over  the  world.  I  must 
confess  my  surprise  that  Sir  Henry  Thompson,  after  employ- 
ing Bigelow's  operation  in  all  its  essential  details  during 
several  years,  and  obtaining  from  it  such  good  results  as  those 
recorded  by  him,  should  still  persist  in  saying*  that  'Bigelow's 
procedure  does  not  introduce  any  principle  or  mode  of  action 
*  '  Diseases  of  the  Urinary  Organs,'  eighth  edition  (1888),  p.  229. 


CONCLUDING  REMARKS  ii7 

that  was  not  employed  before ' ;  and  that  he  should  refrain 
from  accordmg  to  Bigelow  that  credit  to  which  he  is  justly 
entitled  for  his  originality. 

Eeceived  at  first  with  caution,  the  operation  has  steadily 
grown  in  favour'  with  the  profession  all  over  the  world.  In 
the  first  edition  of  this  work  I  wrote :  '  In  India  litholapaxy 
has  as  yet  been  adopted  by  a  few  surgeons  only ;  but  I  am 
convinced  that  the  operation  is  destined  to  play  an  important 
part  in  the  surgery  of  the  future  in  this  country,  where 
unrivalled  opportunities  abound  for  its  practice,  in  reducing 
by  a  large  percentage  the  mortality,  as  well  as  the  suffering, 
attendant  on  stone  in  the  bladder.  I  can  testify  to  the 
immense  popularity  of  the  modern  operation  amongst  the 
natives  of  India ;  and  it  may  be  reasonably  anticipated  that, 
when  it  becomes  generally  known  that  a  small  calculus  may 
be  removed  from  the  bladder  by  an  operation  that  involves 
no  cutting,  little  or  no  pain,  and  confinement  to  hospital  for 
a  few  days  only,  patients  will  present  themselves  for  treat- 
ment at  an  early  stage  of  the  disease,  when  it  is  most 
amenable  to  treatment,  and  when  the  operation  is  almost 
unattended  with  danger.'  That  these  anticipations  have 
been  realized  will,  I  think,  be  acknowledged  when  I  mention 
that  Surgeon-Colonel  Keegan,  who  has  recently  been  collecting 
statistics,  writes  me  that,  in  the  Government  Hospitals  of  the 
North-west  Provinces,  Punjab  and  Bombay  alone,  there  were 
7,694  litholapaxies  performed  in  patients  of  all  ages  in  the 
four  years,  1891-94,  with  255  deaths,  or  a  mortality  of  3*45 
per  cent. !  Sir  Henry  Thompson  tells  us  there  is  nothing 
new  in  Bigelow's  operation.  Let  us  contrast  its  history  in 
India  with  that  of  lithotrity.  How  did  it  happen  that  previous 
to  the  appearance  of  Bigelow  on  the  scene  in  1878,  there  were 
not  half  a  dozen  lithotrities  undertaken  annually  in  the  whole 
of  India  ?  This  was  simply  due  to  the  fact  that,  in  spite  of 
the  persistent  and  able  advocacy  of  Sir  Henry  Thompson  on 


ii8  CONCLUDING  REMARKS 

behalf  of  lithotrity,  the  profession  in  India  looked  askance  at 
it,  and  regarded  lithotomy  as  a  better  operation.  But  in 
litholapaxy  the  profession  saw  a  new  and  distinct  advance  in 
surgery,  and  they  were  not  slow  in  taking  advantage  thereof, 
with  the  result  that  year  by  year  the  tendency  is  for  lithola- 
paxy to  replace  lithotomy  more  and  more. 

Litholapaxy  is  no  longer  on  its  trial :  it  is  now  a  firmly 
established  practice :  it  has  completely  replaced  lithotrity ; 
and  is  destmed  to  replace  all  forms  of  lithotomy,  save  in  very 
exceptional  cases.  The  prejudice  against  the  modern  opera- 
tion that  existed  in  the  mmds  of  many  surgeons,  due  mainly 
to  its  having  been  confounded  with  the  old  operation  of  litho- 
trity, has  been  gradually  vanishmg,  and  must  completely 
vanish  before  the  stern  reality  of  results  such  as  those  recorded 
in  this  monograph.  The  surgeon  who  would  give  his  patients 
suffering  from  stone  the  best  prospect  of  recovery  must  practise 
litholapaxy.  I  believe  I  have  pushed  the  operation,  as  regards 
the  size  and  hardness  of  the  calculi  attacked,  the  ages  and 
debilitated  conditions  of  the  patients  operated  on,  as  far  as 
any  living  surgeon,  and  I  cannot  speak  in  terms  too  high  of 
it.  By  litholapaxy  the  surgery  of  the  bladder  has  been  truly 
revolutionized ;  and  I  confidently  anticipate  that,  with  in- 
creased perfection  m  the  instruments  emploj^ed,  larger  calculi 
than  any  hitherto  attacked  will  successfully  yield  to  the 
operation. 


INDEX. 


Age,  average,  of  patients,  55 
Aspiration  of  debris,  42 
Aspirator,  author's,  27 

Bigelow's,  25 

Golding-Bird's,  35 

Guyon's,  33 

Keegan's,  34 

Morgan's,  34 

Otis's,  35 

Thompson's,  28 

Weiss's,  29 

diagnosis  of  stone  by,  104 

mode  of  using,  43 

removal   of   small   calculi   by, 
105 
Astringent  washings,  50,  100 
Atony  of  bladder,  treatment,  51 

Bigelow's  operation,  9,  37 

a  new  one,  10,  114 
Bladder  injections,  50,  100 

spasm  of,  45 
Blood,  Dr.  J.,  49 

Cadge  on  lithotrity,  111 

on  use  of  Clover's  syringe,  115 
Calculi,  diagnosis  of,  102 

encysted,  67 

impacted,  77 

large,  62 

weights  of,  56 
Cannulse,  23,  82 
Cases  illustrative  of — 

aged  patients,  92 

co-existence  of  enlarged  pros- 
tate, 74 

co-esistence  of  strictm^e,  71 

diagnosis  by  aspirator,  104 

large  calculi,  63 


Cases  illustrative  of — 

longest  time  spent  on  operation, 

93 
no  haemorrhage,  97 
operation  in  children,  85 
rapidity  of  operation,  93 
rapidity  of  cure,  94 
removal  of  small  calculi,  105 
vesico-uretlnral  calculus,  77 
weak  patients,  95 

Cases,  interesting,  92 
not  selected,  55 

Catheter,  evacuating,  23 

Children,  litholapaxy  in,  79 

Civiale's  practice,  15 

Clover's  syringe,  16 

Comphcations  of  operation,  57,  62 

Crampton's  apparatus,  15 

Crushuag  stone,  40 

Cystitis,  58,  99 

Cystoscope,  106 

Deaths  from  htholapaxy,  58 
Diagnosis,  new  method,  104 
Diet  after  operation,  50 
Diificulties  of  operation,  43,  62 

Evacuation  of  debris,  42 

Females,  litholapaxy  m,  89 
Fenwick  on  cystoscope,  106 
'  False  sound,'  46 

Fergusson,  improvement   ia  litho- 
trite,  15 

practice  in  Uthotrity,  16 
Fever  after  operation,  51 
Fracture,  spontaneous,  of  stone,  98 
Fragments  impacted  m  urethra,  47 

in  eye  of  cannula,  47 


INDEX 


Fragments,  disposal  of  last.  47 

Haemorrhage  during  operation,  50 
Harrison  on  new  method  of  diag- 
nosis, 104 
Harrison's  lithotrite,  22 
Hem-telonp's  practice,  15 
Hodgson's  improved  lithotrite,  15 
Holt's  dilator,  71 

niustrative  cases.     See  Cases 
India-rubber  bottle,  100 
Instruments,  litholapaxy,  14 
Interesting  cases,  92 
Introductory,  9 

Keegan's  aspirator,  35 

htholapaxy  in  children,  80 

Litholapaxy,  derivation  of  name,  116 

author's  experience  of,  54 

cases  where  inapplicable,  113 

details  of  operation,  37 

in  childi'en,  79 

in  females,  89 

instruments,  14 

introduced  by  Bigelow,  9 

mortahty  after,  59 
Lithotomy  in  male  childi-en,  79 

results  m  England,  60 

supra-pubic.  112 
Lithotrite,  Bigelow's,  20 

author's,  22 

fenestrated.  18 

flat-bladed,  19 

HaiTison's,  22 

for  children,  80 

introduction  of.  40 

semi-fenestrated,  19 

"Weiss  and  Thompson,  17 
Lithotrity,  history  of,  10 

unsuited  to  India,  11 

Meatus,  enlargement  of,  39 
Noise  in  crushing  stone,  98 


Operating  table,  37 

Operation,  the,  of  htholapaxy,  37 
results  after,  59 
without  anaesthetic,  57 

Otis  on  capacity  of  m*ethra,  23 

Pam  after  operation,  51 
Prostate,  enlargement  of,  73 

Eapidity  of  litholapaxy,  93 
Recurrence  of  stone,  56 

Sex  of  patients,  55 
Sounds,  conical,  38 

Mercier's,  102 

Thompson's,  103 
Spasm  of  bladder,  45 
Statistics  of  author's  operation,  54 

of  hthotomy,  60 
Stone,  catching,  by  hthotrite,  40 

diagnosis  of,  102 

searching  for,  41 

what  is  ?  107 
Stricture,  as  complication,  69 

treatment  of,  69 
Supra-pubic  Hthotomy,  60 

Tenderness  of  abdomen,  51 
Testicle,  swoUen,  51 
Thompson's  aspu-ator,  28 

lithotrite,  17 

urethrotome,  70 
Time  occupied  by  operation,  57 

patients  in  hospital,  55 
Treatment,  preparatory,  37 

after,  50 

Urethi-otome,  89,  70 
Urine,  retention  of,  51 

Vesico-m'ethral  calculi,  77 

Waslung  bladder,  100 

Water,    quantity  dining  operation, 

39 
Weiss's  aspirator,  29 
lithotrites,  14 


THE    END. 


BcMiere,  TindUUl,  and  Cox,  King  William  Street.  Strand. 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RD  581  F94  1896  C.I 

The  moce"  ■'eat~e":  o'  s'0"e  "  :"^e  bla 


2002009692 


